Review of nutrition among Aboriginal and Torres Strait Islander people

Lee A, Ride K (2018) Review of nutrition among Aboriginal and Torres Strait Islander people. Australian Indigenous
HealthInfoNet. From http://healthbulletin.org.au/articles/review-of-nutrition-among-aboriginal-and-torres-strait-islander-people

Introduction
About this review
Acknowledgements
Key facts
The context of Aboriginal and Torres Strait Islander nutrition
Australian dietary guidelines
Nutrition in pregnancy and the early years
Adult and community nutrition
Food security
Costs of poor diet and nutrition
Nutrition programs and services
Aboriginal and Torres Strait Islander nutrition workforce
Policies and strategies
Future directions
Concluding comments
Appendix 1. The Australian Dietary Guidelines
Appendix 2. The Aboriginal and Torres Strait Islander Guide to Healthy Eating
Appendix 3: Data sources and limitations
References

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Introduction

The United Nations General Assembly has proclaimed a Decade of Action on Nutrition from 2016 to 2025 in recognition of the need to eradicate hunger and prevent all forms of malnutrition, including under-nutrition and over-nutrition, worldwide [2]. The Global nutrition report provides context for nutrition issues internationally and in Australia, including those of Aboriginal and Torres Strait Islanders [5].

Aboriginal and Torres Strait Islander people continue to suffer the worst health of all population groups in Australia, with a high burden of disease and low life expectancy [6-9]. The latest available estimates of life expectancy, released in 2013, show that the gap between Aboriginal and Torres Strait Islander and non- Indigenous Australians remains high at 10.6 years for men and 9.5 years for women [10]. A relatively large proportion of Aboriginal and Torres Strait Islander deaths are premature; during the 5-year period 2009–2013, around 81% of deaths among Aboriginal and Torres Strait Islander people occurred before the age of 75 years, compared with 34% of deaths for non-Indigenous people [6].

Poor nutrition is an important factor contributing to overweight and obesity, malnutrition, cardiovascular disease, type 2 diabetes, and tooth decay [11, 12]. Chronic diseases – such as cardiovascular disease, type 2 diabetes, chronic kidney disease and some cancers- are responsible for at least 75% of the mortality gap between Aboriginal and Torres Strait Islander and other Australians [8]. For example, Aboriginal and Torres Strait Islander people are 1.6 times more likely to die from cardiovascular disease and 3-4 times more likely to die from type 2 diabetes than other Australians. Yet these diseases are potentially preventable by modifying risk factors such as being overweight and obese, cigarette smoking, physical inactivity and poor nutrition [6, 10, 13]. Five of the seven leading risk factors contributing to the health gap between Aboriginal and Torres Strait Islander and non-Indigenous Australians – obesity, high blood cholesterol, alcohol, high blood pressure, and low fruit and vegetable intake – relate to poor diet [7]. Combined dietary factors contribute the greatest proportion (27.4%) of all risk factors assessed [7].

Poor diet and nutritional status of Aboriginal and Torres Strait Islander people are influenced by many factors, such as socio- economic disadvantage, and geographical, environmental, and social factors [11, 12].

Very few Aboriginal and Torres Strait Islander people meet dietary recommendations for intake of healthy foods [11, 14]. Also, 41% of their daily energy intake is derived from unhealthy ‘discretionary’ foods and drinks that are high in saturated fat, added sugar, salt and/or alcohol (‘junk’ foods), compared to 35% among non- Indigenous Australians [14-16].

The current poor nutritional health of Aboriginal and Torres Strait Islander people is in marked contrast to the situation prior to European settlement in Australia, when Aboriginal and Torres Strait Islander peoples were generally healthy and enjoyed a varied traditional diet low in energy density and rich in nutrients [12, 17].

About this review

The purpose of this review is to provide a comprehensive synthesis of key information on diet and nutrition among Aboriginal and Torres Strait Islander people in Australia to: (1) inform those involved or interested in Aboriginal and Torres Strait Islander health and nutrition; and (2) provide the evidence for those involved in policy, strategy and program development and delivery. The review provides general information on the historical, social and cultural context of nutrition, and the environmental and behavioural factors that contribute to poor diet and nutrition among Aboriginal and Torres Strait Islander people.

It provides detailed information on food, diet and nutritional health among Aboriginal and Torres Strait Islander people, and links to incidence and prevalence data of diet-related conditions; morbidity, mortality and burden of disease. This review highlights the importance of nutrition promotion and the prevention of diet- related disease, and provides information on relevant programs, services, policies and strategies that help improve food supply, diet and nutritional health among Aboriginal and Torres Strait Islander people. It concludes by discussing possible future directions for combatting the growing epidemic of diet-related ill health among Aboriginal and Torres Strait Islander people in Australia.

This review draws mostly on journal publications, government reports, national data collections and national surveys, the majority of which can be accessed through the HealthInfoNet’s Bibliography.

Edith Cowan University prefers to use the term ‘Aboriginal and Torres Strait Islander’ rather than ‘Indigenous Australian’ for its publications. However, when referencing information from other sources, our authors are ethically bound to utilise the terms from the original source unless they can obtain clarification from the report authors/copyright holders. As a result, readers may see these terms used interchangeably with the term ‘Indigenous’ in some instances. If they have any concerns they are advised to contact the HealthInfoNet for further information.

Acknowledgements

Special thanks are extended to:

• authors of relevant reviews published previously by the Australian Indigenous HealthInfoNet, particularly Dr Neil Thomson, Jennifer Brown and Sharon Thorpe, whose work has informed this current revision
• the anonymous reviewer whose comments greatly assisted finalisation of this review
• other staff at the Australian Indigenous HealthInfoNet for their assistance and support
• the Australian Government Department of Health for their ongoing support of the work of the Australian Indigenous HealthInfoNet.

Key facts

• Aboriginal and Torres Strait Islander people continue to suffer the worst diet-related health of all population groups in Australia.
• Diet-related chronic diseases – such as cardiovascular disease, type 2 diabetes, chronic kidney disease and some cancers – are responsible for at least 75% of the mortality gap between Aboriginal and Torres Strait Islanders and other Australians.
• In 2011, 13 dietary factors were identified as being risk factors for the Australian population (out of 29 risk factors). When combined, the joint effect of all dietary risks combined contributed 9.7% to the burden of disease for Aboriginal and Torres Strait Islander people.
• The nutrition burden among Aboriginal and Torres Strait Islander adults is underscored by malnutrition, which includes both over-nutrition (particularly over-consumption of unhealthy ‘discretionary’ foods) and under-nutrition (dietary deficiencies related to inadequate intake of healthy foods).
• In 2012-13, very few Aboriginal and Torres Strait Islander adults or children consumed adequate amounts of healthy foods consistent with recommendations of the Australian Dietary Guidelines. Furthermore, over two-fifths (41%) of total daily energy reported by Aboriginal and Torres Strait Islander people came from unhealthy foods and drinks classified as ‘discretionary’.
• The current situation is in marked contrast to the situation prior to European settlement of Australia. All available evidence suggests that Aboriginal and Torres Strait Islander Australians were traditionally healthy; enjoying varied dietary patterns of fresh plant and animal foods, low in energy density and rich in nutrients.
• Many historical, socioeconomic, environmental and geographic factors contribute to the current poor diet, nutrition and food security experienced by Aboriginal and Torres Strait Islander people.
• In 2012-13, 66% of Aboriginal and Torres Strait Islander people aged 15 years or older were classified as overweight (29%) or obese (37%); a further 30% were normal weight and 4% were underweight. In addition, 30% of Aboriginal and Torres Strait Islander children aged 2-14 years were overweight (20%) or obese (10%); 62% were in the normal weight range and 8% were underweight.
• Prevalence of poor pregnancy outcomes and infant malnutrition remains high in many areas. Low birthweight, failure to thrive and poor child growth are still serious concerns in many Aboriginal and Torres Strait Islander communities.
• In 2012-13, 83% of Aboriginal and Torres Strait Islander children aged 0-3 years had been breastfed, compared with 93% of non-Indigenous children. Of those who were breastfed, Aboriginal and Torres Strait Islander infants were less likely than non-Indigenous infants to have been breastfed for 12 months or more (12% compared with 21%).
• Based on self-reported usual serves of vegetables eaten per day, only 8% of Aboriginal and Torres Strait Islander people met the vegetable intake recommended in the Australian Dietary Guidelines. Mean reported vegetable intake was less than a third of the recommended amount.
• Based on self-reported usual serves of fruit eaten per day, 54% of Aboriginal and Torres Strait Islander people met the fruit intake recommended in the Australian Dietary Guidelines. Mean reported fruit intake was around half the recommended amount.
• One-quarter (25%) of grain (cereal) foods consumed by Aboriginal and Torres Strait Islander people were from wholegrain and/or high fibre varieties, compared to the recommended 50% or more.
• The average daily consumption of milk, yoghurt, cheese and alternatives for each age-sex group of Aboriginal and Torres Strait Islander people, with the exception of children aged 2-3 years and girls 4-8 years, was considerably lower than the respective recommend number of serves.
• The average daily consumption of lean meats and meat alternatives for each age-sex group of Aboriginal and Torres Strait Islander people, with the exception of girls 2-3 years, was less than the respective recommendations; intake was relatively high in remote areas.
• On average, Aboriginal and Torres Strait Islander people 2 years and over reported consuming an average of 75g (18 teaspoons) of free sugars per day, which equates to an average of 14% of dietary energy, nearly 50% more than World Health Organization (WHO) recommendations. Two-thirds of Aboriginal and Torres Strait Islander people’s free sugar intake came from sugary drinks.
• In 2011-2013, 22% of survey respondents said they had run out of food and couldn’t afford to buy more in the last 12 months. Aboriginal and Torres Strait Islander people in remote areas were more likely to run out of food than those in non- remote areas (31% and 20% respectively).
• The underlying causes of food insecurity in Aboriginal and Torres Strait Islander communities include factors such as low income and unemployment, inadequate housing, over- crowding, lack of educational opportunities, transport, high food costs, cultural food values, food and nutrition literacy, knowledge and skills.
• A range of general Australian Government Department of Health programs contribute to the prevention and management of diet-related disorders among Aboriginal and Torres Strait Islanders at a national level. However, since the expiry of the National Aboriginal and Torres Strait Islander nutrition strategy and action plan 2002-2010, there has been no national coordination of nutrition efforts in Australia.
• Several community-based nutrition programs have demonstrated positive outcomes in the past. The most effective programs have adopted a multi-strategy approach, addressing both food supply (availability, accessibility and affordability of foods) and demand for healthy foods. A major success factor is community involvement in (and, ideally, control of) all stages of program initiation, development, implementation and evaluation, to ensure the intervention is culturally appropriate and tailored to community needs.
• Programs to improve food supply have included a focus on: food retail outlets; local food production, such as school or community gardens; food provided by Aboriginal and Torres Strait Islander and community organisations; and food aid. Community store nutrition policies have been shown to be important influences on the food supply and dietary intake in remote areas.
• While nutrition education alone will not improve food security or dietary intake, it can be effective when combined with a range of other strategies to help people access healthy food, such as cooking programs, peer education, budgeting advice, and group-based lifestyle modification programs.
• A well-supported, resourced and educated Aboriginal and Torres Strait Islander nutrition workforce is essential for the success of nutrition interventions.
• There is a long history of effort to improve nutrition and food security among Aboriginal and Torres Strait Islander people, however there is no current national nutrition policy or strategy in place.
• Improving food supply and security to better prevent and manage poor nutrition and diet-related disease is vital to the current and future health of Aboriginal and Torres Strait Islander Australians. Food and nutrition programs play an important role in the holistic approach to improving health outcomes for Aboriginal and Torres Strait Islander people.

The context of Aboriginal and Torres Strait Islander nutrition

It is beyond the scope of this review to discuss in detail the underlying social and cultural determinants that influence the nutritional status of Aboriginal and Torres Strait Islander people. However many historical, socioeconomic, environmental and geographic factors contribute to the poor diet, nutrition and food insecurity currently experienced by Aboriginal and Torres Strait Islander people. Among these are: lower incomes; lower educational opportunities and attainment; higher rates of unemployment; disruption to family structures; poorer access to a healthy and affordable food supply; poorer access to health infrastructure, such as adequate housing, compared to the broader Australian community [11].

It has been estimated that between one-third and one-half of the health gaps between Aboriginal and Torres Strait Islanders and non-Indigenous Australians are associated with differences in socioeconomic position [8]. In particular, Aboriginal and Torres Strait Islander people suffer substantial disadvantage across a range of social determinants that underpin poor nutritional health status [11, 12, 18]. Among these are: lack of control over circumstances; poverty; lower income and unemployment; lower levels of education; disrupted family and community cohesion; social marginalisation; stress; substance abuse; inadequate and overcrowded housing; inadequate sanitation, water supplies and hygiene; limited access to transport; and incarceration, discrimination and racism.

Historical factors

Many historical factors continue to impact on the diets of Aboriginal and Torres Strait Islander people today. Although European settlement severely affected the retention of knowledge, access to, and use of traditional foods [12, 19], strong culture, values and a connection to the land contribute to the resilience of Aboriginal and Torres Strait Islander peoples today.

Traditional diet and health

Aboriginal people first arrived in Australia at least 50,000 years ago, with recent genetic evidence suggesting dates as early as 75,000 years ago, making Aboriginal Australians one of the oldest continuous populations living outside of Africa [20]. Hunter- gatherer life was usual until about 12,000 years ago, when human groups, including in Australia, started to experiment with plant production [21].

Aboriginal people had a strikingly detailed knowledge of their country, including the availability of water, and the impact of the annual cycle of seasonal changes on availability and lifecycle of particular plant and animal foods [12, 22-24]. Diets were omnivorous and could vary greatly from day-to-day and season- to-season. In many parts of the country, dietary patterns tended to be subsistence with occasional feasts, sometimes referred as ‘feast and famine’. The capacity to devour large quantities during abundance was an important survival strategy, along with minimizing ‘unnecessary’ energy expenditure, enabling excess energy to be stored as fat to help people survive times of food shortage [12, 24, 25].

Traditional Torres Strait Islander diets varied from island to island. Seafoods such as fish and shellfish were an important component of the diet, and turtle and dugong had a central place in cultural life, as did the keeping of pigs. Gardening was vital, not only for subsistence but to provide food for ceremonies and trade. Traditional crops included taro, yams, bananas and coconuts. Several plant foods were stored and preserved [12, 25].

Men and women both contributed importantly to food procurement. Women generally provided the subsistence diet: diverse plant foods, honey, eggs, small mammals, reptiles, fish, shellfish, crustaceans and insects. They usually obtained foods in groups with their children — passing on knowledge and skills to the next generation while the men tended to hunt for larger game (such as kangaroo, wallaby, emu, turtle, crocodile and dugong). It has been claimed that hunter-gatherers spent less time (three to five hours/day) ensuring their livelihood than agriculturalists and the full-time employed today, however food procurement and preparation was very energy-intensive [12, 24].

Animal foods:

All animals were potential food sources; mammals, birds, reptiles, insects and all marine species. Everything edible on an animal carcass was eaten and bones were chewed. One of the most striking features of wild animals is their leanness in comparison with meats from animals domesticated for human consumption; the fat in wild animals tends to be less saturated too [12, 24].

Plant foods:

Traditionally Aboriginal people consumed a very wide range of wild plant foods: tuberous roots, legumes, seeds (including wild rice), nuts, fruits, berries, nectars, flowers, gums, and lerp ¹. Relative to their cultivated forms, wild plants tend to be high in dietary fibre and contain carbohydrate that is slowly digested, low in starch and sugars, and rich in many bioactive phytochemicals (e.g. flavonoids, polyphenols) with antioxidant and anti-inflammatory properties [12, 24].

Food preparation and patterns of intake:

Traditional food preparation generally resulted in minimal loss of nutrients. Many plant foods, such as fruits, bulbs, gums, flowers and nectars were consumed fresh and raw as they were collected. Foods were processed to help make them more digestible or palatable, for example, baking starchy tubers, grinding and roasting seeds and cooking meat. The most highly prized components of the traditional diet were the relatively few energy-dense foods high in fat or sugar, including land and marine animal fat, bone marrow, organ meats, eggs, fatty insects and honey. Food was usually eaten when it was available, with little wastage [12, 24].

Infant feeding:

Traditionally children were universally breastfed until they were about three to four years old. If the need arose, other lactating women would substitute for the mother. The age of weaning often depended on the arrival of a younger sibling [12, 26]. Young children were usually fed breastmilk and food on demand [12].

Health:

Traditional foods promoted physical health as well as cultural, spiritual and emotional health. Available information on the nutrition of Aboriginal and Torres Strait Islander people prior to European colonisation indicates that they were extremely lean, physically fit and strong [21-23, 27, 28]. In the most remote areas of Australia small groups continued to live as hunter-gatherers well into the 20th century; studies with these groups show they exhibit no evidence of the chronic diseases that plague others today [29]. For more information, see Box 1.

Box 1: Traditional foods and the benefits of a hunter-gatherer lifestyle

In remote Australia, many older Aboriginal people retain the knowledge and ability to live as hunter-gatherers. The health benefits of temporary reversion to traditional hunter gatherer life were illustrated by a small group of diabetic people in the West Kimberley in the early 1980s [1]. Among the dramatic health improvements seen, after only seven weeks “living off the land” in their traditional country they lost weight and their metabolic indicators and risk factors for diabetes and cardiovascular disease normalised. People rarely complained of hunger; although their diet was low in energy (1200 kcal/day) it was high in protein (54% energy), with 33% carbohydrate, and 13% fat. While reverting to a hunter-gatherer lifestyle is not a realistic option for the vast majority of Aboriginal and Torres Strait Islander people who live in towns and cities today, in some remote communities people do regularly hunt animal foods and collect plant foods to supplement the foods they buy from the store. The model of the hunter-gatherer diet and lifestyle can be used also as a benchmark, and as a guide to healthier patterns of eating and lifestyle.

Transitional diet post contact

After European settlement in 1788, there was decreased access to and availability of traditional foods, and Aboriginal people were increasingly forced to become dependent on introduced foods [12, 22, 23, 30]. These were primarily‘rations’ of flour, sugar, tea, tobacco and to a lesser extent meat (fresh, tinned or salted). The durability, transportability, low bulk, affordability and the simple cooking and storage facilities required for their preparation may still influence popularity of these foods today.

As hunter-gatherer life, although healthy, could also be very difficult, many Aboriginal people opted to visit or stay on cattle stations, missions and government settlements, where at least some food was provided on a regular basis. The available foods being high in fat and sugar, such as jam, sugar and tinned meat, also tended to reflect the most highly prized traditional foods. In particular, sugar was eagerly sought and was consumed in large quantities from early contact. Basic rations were supplemented with irregular quantities of fruit and vegetables from the local gardens in missions and government settlements, and where possible, with traditional bush food.

Communal dining rooms were established at many settlements and missions and tended to be the only option to obtain food, especially prior to 1969 when Aboriginal and Torres Strait Islander people did not receive all their wages in cash [12]. Communal feeding disrupted traditional food distribution, contributed to the loss of knowledge in food preparation and cooking methods and lessened responsibility for the economic management of food and the feeding of children.

Available dietary studies of Aboriginal people during these times showed low intakes of energy, protein and several micronutrients including calcium, iron, vitamin A, vitamin B12 and vitamin C, reflecting dietary patterns that were higher in flour, bread and poor quality meats, but lower in fruit, vegetables and dairy foods, than for other Australians [12].

Socioeconomic factors

Occupation, income and wealth play important roles in socioeconomic position, and also in health. Higher incomes support greater access to goods and services that provide health benefits, such as better food and housing, health care options, and preventative health activities. Loss of income through illness, disability or injury can adversely affect individual socioeconomic position and health [10].

The 2012-2013 Australian Aboriginal and Torres Strait Islander health survey (AATSIHS) examined associations between ‘dietary behaviour’ and employment status [31]. Reported fruit and vegetable intake were used as a proxy for dietary behaviour.

After age-adjustment, unemployed Aboriginal and Torres Strait Islander people were more likely to have an inadequate daily fruit intake (63%) and inadequate vegetable intake (98%) than those who were employed (54% and 94% respectively) or not in the labour force (60% and 95% respectively).

Aboriginal and Torres Strait Islander households have, on average, a weekly gross income which is $250 less than that of non- Indigenous households [6]. In the 2014-15 National Aboriginal and Torres Strait Islander social survey (NATSISS), the unemployment rate for Aboriginal and Torres Strait Islander people aged 15 years and over was 20.6%, much higher than the 12.7% for Australians as a whole [32].

Aboriginal and Torres Strait Islanders who are unemployed suffer greater risk of poor health through poor diet – such as lower levels of fruit and vegetable consumption – as well as higher rates of smoking and substance use compared with Aboriginal and Torres Strait Islanders who are employed [10]. However, there tends to be a higher prevalence of overweight and obesity among employed Aboriginal and Torres Strait Islander adults compared to those who are unemployed [10].

Educational attainment is associated with better health throughout life. The 2012-2013 AATSIHS examined associations between dietary behaviour and educational attainment [31]. Aboriginal and Torres Strait Islander people who had completed year 10 or below were more likely to consume inadequate amounts of fruit (59%) and vegetables (95%) than those who had completed year 12 or higher (54% and 93% respectively).

Affordability of healthy diets is affected by both household income and food prices. Purchasing a healthy diet is estimated to cost 20-31% of the disposable household income of low income families, compared with 14-18% for those on a median disposable income [33-35]. Food affordability is lowest in remote Aboriginal and Torres Strait Islander communities, as food prices are higher in remote locations than in urban areas, yet median income is lower in remote areas.

Since the early 1990s, surveys of the cost of a basket of foods have consistently shown that prices in remote Aboriginal and Torres Strait Islander communities are up to 50% more expensive than in the nearest capital cities [36]. There are also fewer opportunities to purchase advertised foods at discounted prices in remote areas [37, 38].

In remote Aboriginal communities, foods of relatively high energy density (such as oil and flour) tend to be cheaper per unit of energy than nutrient dense foods (such as most fruit and vegetables) [37], but are not always cheaper when price is assessed by nutrient density or by other units, such as weight [39]. Purchase of other items (such as cigarettes and alcohol) can also impact on the food budget [6].The exemption of 10% goods and services tax (GST) from basic, healthy foods in Australia helps to increase the affordability of healthy diets, especially among low socioeconomic households [34, 40].

Environmental factors

The physical environment in which many Aboriginal and Torres Strait Islanders live also has significant implications for nutritional status [6, 12]. The elimination of overcrowding and the provision of appropriately designed, constructed and maintained houses are essential for the safe storage, preparation and consumption of food [38]. Access to water for drinking and washing, and safe sewage and garbage disposal are critical to health [41].

According to the Australian Institute of Health and Welfare (AIHW) analysis of the 2012-13 AATSIHS, 15% of Aboriginal and Torres Strait Islander households reported living in a dwelling that was lacking at least one working facility such as a fridge or cooking facility, toilet, bath or shower [6]. In Aboriginal communities across Australia only 6% of houses have all of the functioning health hardware needed to store, prepare and cook food, such as cupboards, bench space, refrigeration and a functioning stove and sink [42].

According to the 2011 census, overcrowding is improving in Aboriginal households but around 13% of Aboriginal and Torres Strait Islander households were overcrowded compared to 3% of other households [6]. Overcrowding impacts around one in five people nationally and more than a third of Aboriginal and Torres Strait Islander people in remote areas [32].

Geographic factors

Although most Aboriginal and Torres Strait Islander people live in metropolitan and regional areas, a much larger proportion live in remote or very remote areas than do non-Indigenous people (21% compared with 2%) [6]. The relatively small proportion of Aboriginal and Torres Strait Islander people who live in remote areas experience 40% of the health gap of Aboriginal and Torres Strait Islander Australians overall [43].

One of the contributing factors is the reduced variety and quality of nutritious foods in remote communities in Australia [44-48]. Healthy food baskets also cost up to 50% more in remote areas than in major cities [36, 46, 49]. It has been estimated that 34-80% of the income of Aboriginal families in remote areas is needed for healthy diets – at least twice that required by non-Indigenous families in urban areas [30, 50]. Factors contributing to the higher costs of foods in rural and remote areas are: increased freight costs; higher store overheads (such as capital costs of building and maintaining long-term storage facilities and accountancy costs); the greater wastage of food stock [46]; some store management practices [47, 51]; and the reduced economies of scale for

purchasing and retailing in small remote communities [44, 52-55]. Healthy food items are less available in remote stores, particularly fresh fruit and vegetables, whole grain cereals, lean meats and low fat dairy products [44-46, 48, 56]. Communities in remote areas may also be without food for extended periods due to weather or road conditions, such as during the wet season, although recent Northern Territory (NT) market basket surveys suggest this may be improving [56].

Australian dietary guidelines

The Australian dietary guidelines [11] are presented in Appendix 1.

Although the Australian dietary guidelines are relevant to Aboriginal and Torres Strait Islander peoples, they also provide specific recommendations for this population group. Specific Aboriginal and Torres Strait Islander dietary recommendations include to enjoy traditional foods whenever possible, and when choosing store foods, to choose those most like traditional bush foods, such as fresh plant foods, wholegrain (cereal) foods, seafood, and lean meats and poultry.

The guidelines note that:

• lactose intolerance after the age of 3–5 years may be problematic in some areas or for some individuals, therefore alternative food sources of calcium are recommended in these cases
• consumption of traditional bush foods should be supported wherever possible
• breastfeeding should be encouraged and supported – the nutritional and immunological benefits of breastfeeding are particularly important in populations with a high prevalence of high risk infants, such as Aboriginal and Torres Strait Islander Australians
• children and adolescents require sufficient nutritious food to grow and develop normally and the growth of young children should be checked regularly.

The World Health Organization (WHO) recommends that both adults and children consume less than 10% of dietary energy from free sugars [57]. This is consistent with the Australian dietary guidelines, as most Australians following the guidelines would consume less than 5% of dietary energy from free sugars [58].

The graphic Aboriginal and Torres Strait Islander guide to healthy eating is included in Appendix 2.

Nutrition in pregnancy and the early years

Good maternal nutrition and healthy infant and childhood growth are fundamental to the achievement and maintenance of health throughout life. The potential intergenerational effects of poor health and nutritional status in early life, including the effect of gestational diabetes, have been well documented; the foundations of adult health are laid in utero and during the perinatal and early childhood periods [59-61].

Maternal and perinatal outcomes of Aboriginal and Torres Strait Islander mothers and their babies have consistently been shown to be poorer than those of non-Indigenous mothers [62]. Key factors include younger maternal age, remoteness and socioeconomic disadvantage.

From 2001 to 2014, the mortality rate for Aboriginal and Torres Strait Islander infants fell from 1,121 deaths per 100,000 births to 638 deaths per 100,000 births, a decrease of 43% [62]. This reflects improvement in the underlying rates of disease, as well as increased health-service utilisation, accessibility and effectiveness. The rate of decrease in mortality for Aboriginal and Torres Strait Islander infants was almost twice that for all infants; however Aboriginal and Torres Strait Islander infant mortality remains almost twice that of non-Indigenous infants [62, 63]. Aboriginal and Torres Strait Islander infant mortality rates vary across jurisdictions, from around six per 1,000 in South Australia (SA), to 13 per 1,000 in the Northern Territory NT [8].

Prevalence of poor pregnancy outcomes and infant malnutrition remains high in many areas and low birthweight, failure to thrive and poor child growth are still serious concerns in many Aboriginal and Torres Strait Islander communities [64]. Iron deficiency anaemia among young Aboriginal and Torres Strait Islander children is also common [12, 65]. For example, a recent clinical audit in Cape York found that 32% of the children aged from 6-24 months were anaemic at their last haemoglobin test [66].

Intra-uterine growth

Good nutrition prior to conception and during pregnancy is crucial, as it influences both the mother’s own health and that of her baby. Low dietary-energy intake, malnutrition, inadequate weight gain during pregnancy, and low pre-pregnancy weight can lead to intra-uterine growth retardation, which in turn can reduce birthweight [59]. Being overweight or obese during pregnancy contributes to an increased risk of complications (particularly for the mother) during pregnancy and delivery, including increased morbidity and mortality for both mother and baby [62]. Other factors that can negatively influence intra-uterine growth include substance use in pregnancy (particularly cigarette smoking and alcohol consumption) [6, 10, 62].

According to the study, Australia’s mothers and babies 2014, pregnant Aboriginal and Torres Strait Islander women were more likely to smoke cigarettes than non-Indigenous pregnant women (46% compared to 12%) [62]. Conversely, fewer Aboriginal and Torres Strait Islander women drink alcohol than non-Indigenous women (71% compared with 77% respectively) [67]. In 2011-12 Aboriginal and Torres Strait Islander women of child bearing age (18-44 years) were less likely to drink at low-risk levels than non-Indigenous women of child bearing age (28.4% compared with 42%), but more likely to drink at risky/high risk levels (11.6% compared with 9.5%) [67]. The prevalence of Fetal alcohol syndrome disorder (FASD) is high among indigenous populations internationally and has significant nutrition implications [68].

Birthweights

Birthweights below 2,500 grams – defined as ‘low birthweight’ – increase the risk of death in infancy and other health problems [6, 10, 62]. Low birthweight may be a result of fetal growth restriction, preterm birth, or a combination of the two [12]. The impact of maternal nutrition on birthweight was demonstrated in a study of 503 infants born to Aboriginal mothers in the Darwin region between 1987 and 1990 [69]. The study found that underweight mothers (with a body mass index (BMI) of less than 18.5)² had five times the risk of having a low-birthweight baby and over two-and-a-half times the risk of their baby suffering intra-uterine growth retardation. Overall, the study found that 28% of cases of low birthweight and 15% of cases of growth retardation could be attributed to maternal malnutrition.

As discussed previously, many factors other than the nutritional health of the mother can influence birthweight; low birthweight can be considered a proxy indicator of the early start to socioeconomic disadvantage of Aboriginal and Torres Strait Islander children [10].

In 2013, babies born to Aboriginal and Torres Strait Islander mothers were twice as likely to be of low birthweight as babies born to other Australian mothers (12.2% compared with 6.1%) [62]. While the average rate of low birthweight babies born to Aboriginal and Torres Strait Islander mothers decreased slightly from 12.7% in 2000 to 12.2% in 2013 [13, 62, 70], there is wide variation throughout the country. The proportion of low birthweight babies with Aboriginal and Torres Strait Islander mothers has remained between 11.8% and 13.2%, and the proportion of those with non- Indigenous mothers has remained between 5.9% and 6.2% over this time [62].

Breastfeeding

The nutritional and immunological benefits of breastfeeding are particularly important in populations with a high prevalence of high risk infants – such as those of low birthweight or those born to diabetic mothers. Breastfeeding is particularly important in communities that may have limited access to a good quality water supply, limited financial resources and a high prevalence of infectious diseases; it is convenient, hygienic, requires no special equipment, and is significantly cheaper than bottle-feeding [11, 12, 17].

Breast milk is the natural and optimum food for babies and provides all the energy and nutrients that an infant needs for the first six months of life [11, 71]. Breastfeeding promotes sensory and cognitive development and protects the infant against sudden infant death syndrome (SIDS), asthma, infectious diseases and chronic diseases later in life. Exclusive breastfeeding aids a quicker recovery from illness and reduces infant deaths from common childhood illnesses such as diarrhoea or pneumonia. The Australian dietary guidelines recommendation is to ‘encourage, support and promote breastfeeding’. The National Health and Medical Research Council (NHMRC) recommends exclusive breastfeeding for around six months, and breastfeeding, with appropriate complementary foods, until 12 months of age and beyond, as long as the mother and child desire; while breastfeeding is recommended for 6 to 12 months and beyond, any breastfeeding is beneficial to the infant and mother [17]. The WHO recommends exclusive breastfeeding for six months followed by complementary feeding with continued breastfeeding for up to two years or beyond [71]. Breastfeeding contributes to the health of the mother by reducing the risk of ovarian and breast cancers and weight gain in later life [11, 17].

According to the 2012-13 AATSIHS, 83% of Aboriginal and Torres Strait Islander children aged 0–3 years had been breastfed, compared with 93% of non-Indigenous children [6]. Aboriginal and Torres Strait Islander children aged 0–3 years were 2.3 times more likely than non-Indigenous infants to have never been breastfed (17% compared with 7% respectively). Of those who had been breastfed, Aboriginal and Torres Strait Islander infants were more likely than non-Indigenous infants to have been breastfed for less than one month (16% compared with 10% respectively). Aboriginal and Torres Strait Islander infants were less likely than non-Indigenous infants to have been breastfed for 12 months or more (12% compared with 21% respectively). Breastfeeding rates of Aboriginal and Torres Strait Islander children aged 0–3 years did not vary significantly by remoteness, 82% in non-remote areas and 84% in remote areas were breastfed.

Similarly, according to the 2010 Australian national infant feeding survey, breastfeeding initiation levels were similar among Aboriginal and Torres Strait Islander and non-Indigenous mothers (87% and 90% respectively), but levels of exclusive breastfeeding declined more rapidly among Indigenous mothers (derived from [72]). At five months of age only 11% of Aboriginal and Torres Strait Islander babies were exclusively breastfed, compared with 27% of non-Indigenous babies.

A recent study of infant feeding behaviour among Aboriginal women in rural Australia [73] concluded that lack of intergenerational support, unsupportive social factors and the pervasive presence of infant formula produced strong barriers to breastfeeding. Previous studies also cited cracked or sore nipples, tiredness, a mother’s belief that she produces insufficient milk or very low infant birthweight as reasons for not breastfeeding, with similar reasons given among Aboriginal and Torres Strait Islander women as non-Indigenous women [12, 74].

Commencing in 2008-2009, the Footprints in time – the longitudinal study of Indigenous children collects data annually from 11 sites (rural, remote and urban) and up to 1,700 Aboriginal and Torres Strait Islander children around Australia [75]. Data on breastfeeding from this study showed that 80% of Aboriginal and Torres Strait Islander children had been breastfed at some time during their early years, and 22% of infants had been breastfed for at least 12 months. This study found that children living in more remote areas had been breastfed for a slightly longer period of time than those living in other areas [75].

Growth of infants and children

The growth of infants and children is an important marker of their health and development; disturbances in health and nutrition almost always affect growth [11]. Like poor growth in utero, poor growth in early childhood is associated with both short and long term health effects, including increased rate of acute infection and development of chronic diseases in later life [61, 76, 77]. Over-nutrition and obesity in infancy and childhood are also linked to poorer health outcomes [11]. Body size and growth velocity outside the ‘normal’ range during the early years of life are both associated with risk of overweight and obesity later in childhood and adulthood [11, 64, 78].

Healthy growth depends on a favourable combination of genetic and environmental influences [11, 12]. Environmental determinants of normal growth include good maternal health during pregnancy and healthy weaning and feeding practices. Growth can be hampered by under-nutrition (inadequate quantity of food and energy intake), malnutrition (inadequate quality of food), specific nutritional deficiencies, anaemia, infections and parasitic infestations.

Growth retardation among Aboriginal infants from around six months of age has been documented frequently since first assessed in the 1960s [11, 12, 17]. Many Aboriginal babies, characteristically lighter and smaller than non-Indigenous babies, were found to grow well over the first four to six months, followed by a fall-off in growth lasting until about three years of age. A similar overall pattern was also found for head growth [12]. This pattern of growth was thought to be a genetic characteristic, but studies subsequently demonstrated ‘normal’ growth in Aboriginal and Torres Strait Islander children exposed to reasonable living conditions [12, 64].

The general pattern of faltering growth appears to have persisted, at least in rural and remote areas of the NT and the Kimberley region of Western Australia (WA). Although there appears to have been some improvement since the 1960s [64, 79], there is a paucity of recent national data on growth of Aboriginal and Torres Strait Islander infants.

The recording of relatively poor growth of Aboriginal children living in remote areas of the NT resulted in the establishment in the late 1990s of the Growth Assessment and Action (GAA) Program, now called the Healthy Under 5 Kids Program [80]. More information about the program is included in Box 2.

A review of the program, undertaken in 2015, assessed at least one health measure in 3,497 of 3,850 (91%) children aged less than five years of age living in rural and remote communities; all data were available for less than 75% of children. Overall, the current levels continue the very gradual improvements in growth status that have occurred since the late 1990s [80].

According to the review, 15% of children were assessed as ‘stunted’ (more than two standard deviations below the median height for age of the reference population), 6% as ‘underweight’ (more than two standard deviations below the median weight for age) and 5% as ‘wasted’ (more than two standard deviations below the median weight for height) (Table 1). Of children between the ages of six months to five years, 17% were anaemic.

Table 1 Summary of results of the Healthy under 5 kids program, Northern Territory, 2015

Source: National Health and Medical Research Council, 2013 [11]

Appendix 2. The Aboriginal and Torres Strait Islander Guide to Healthy Eating

Source: National Health and Medical Research Council, 2015 [280]

Appendix 3: Data sources and limitations

The two major data limitations in Aboriginal and Torres Strait Islander nutrition are data gaps and bias.

Dietary data

The execution of the National Aboriginal and Torres Strait Islander nutrition and physical activity survey (NATSINPAS) 2011-2013, a component of the Australian health survey 2011-13, was the first time nationally representative food and nutrition data and related biomedical data for Aboriginal and Torres Strait Islander people had been collected [6]. As noted by the AIHW [10], available data are too sparse to produce consistent time series, to regularly assess changes in dietary risk factors, or explain their contribution to the health gaps between the Aboriginal and Torres Strait Islander and non-Indigenous populations, and the health inequities within the Aboriginal and Torres Strait Islander population. Some data items are collected only from Aboriginal and Torres Strait Islander people living in non-remote locations.

Numbers of Aboriginal and Torres Strait Islander participants in the NATSINPAS 2011-2013 [14, 92] were too small to produce reliable estimates of the prevalence of risk factors in Aboriginal groups compared with Torres Strait Islander groups. However some metrics, for example, anthropometry and intake of some foods, such as seafood, are known to be very different in each of these populations [11].

The Australian Bureau of Statistics (ABS) has noted that significant under-reporting of dietary intake is likely in both the 2012-13 NATSINPAS and 2011-12 National nutrition and physical activity survey (NNPAS) [281]. There appears to be a higher rate of under- reporting in the NATSINPAS (mean energy missing 27%), for both males (mean energy missing 24%) and females (mean energy missing 31%), than in the NNPAS (mean energy missing 19%). Under-reporting appears to be more prevalent among females than males, increases with age and increases as BMI increases [281].

Also, the ABS note [281] that given the association of under- reporting with overweight/obesity and consciousness of socially acceptable/desirable dietary patterns, under-reporting is unlikely to affect all foods and nutrients equally; that is, people are likely to over-report healthy foods and under-report discretionary foods. A recent study comparing dietary estimates from the NATSINPAS to food and beverage purchase data has confirmed such likely self- reporting bias [282].

Very limited data are collected regularly on Aboriginal and Torres Strait Islander food and nutrition in Australia. The regular Aboriginal and Torres Strait Islander health survey reported by the AIHW collects only data on intake of number of serves per day of fruit and vegetables by self-reported methods in non-remote areas [6]. Such self-reported dietary intakes have been shown to be highly unreliable in Aboriginal communities [86] and these data are likely to be over-estimated for the reasons outlined by the ABS [281].

Little recent data are available concerning the full range of nutrition issues, such as infant growth or risk factors for poor pregnancy. Data for specific age/gender groups are also sparse, such as for adolescents and older Aboriginal and Torres Strait Islander groups. For example, despite the prominence of Fetal alcohol spectrum disorder (FASD), current data on alcohol use in pregnancy are from the National drug strategy household survey and thus are based only on a small number of pregnant women; due to the sample size, further disaggregation (for example, by Indigenous status, remoteness or socioeconomic position) is not possible [10].

Food security

Over 20 years ago the Australian national nutrition survey (1995) included a single question around individual food security: ‘In the last 12 months, were there any times that you ran out of food and couldn’t afford to buy any more?’ [283]. A similar question was again included in the 2004-05 National Aboriginal and Torres Strait Islander health survey (NATSIHS) which collected information from 10,439 Aboriginal and Torres Strait Islander people from remote and non-remote areas across Australia [284]. While a useful indicator, it is likely to underestimate the degree or nature of food security problems, as the question only addresses one aspect of food security (running out of food as a result of running out of money). It has also not been possible from this limited information to isolate nutrition and food security data for the majority of Aboriginal and Torres Strait Islander people that live in urbanised environments. There is a need to better understand food insecurity from an Aboriginal and Torres Strait Islander perspective and to develop specific tools for assessment.

Monitoring activities can focus, as in the above example, on measuring the prevalence of food security for particular groups (that is quality of food, shortage of food, experiences of hunger, anxiety about food intake). Another approach is to assess the determinants of food security, in relation to the factors which impact ‘food supply’ and ‘food access’. Examples here may include:

• documenting the price, availability, quality and promotion of food in community retails outlets
• mapping the location of supermarkets and other food outlets in relation to residential areas
• monitoring the uptake of food aid programs.

Anthropometry

In the 2012–13 AATSIHS, measures of height and weight were collected to determine BMI. These measured BMI data for 2012–13 are not comparable with previous ABS national Aboriginal and Torres Strait Islander health surveys or national health surveys, in which BMI were mainly based on (highly unreliable) self-reported height and weight [10, 67] . However, several reports compare these data [10].

Representativeness of sampling is also a challenge in interpreting survey results. In the 2012–13 AATSIHS, BMI was only calculated for people for whom both height and weight were measured. In 2012–13, 80.6% of Aboriginal and Torres Strait Islander people aged two years and over had their height and weight recorded. Height and weight measurements were obtained from 76.7% of Aboriginal and Torres Strait Islander children aged 2–14 years, and 82.5% of Aboriginal and Torres Strait Islander people aged 15 years and over [10].

There is a lack of national growth data for Aboriginal and Torres Strait Islander infants in Australia; such data are collected, analysed and reported routinely only in the NT [274].

Implication of data issues

Gaps and bias in food, nutrition and diet-related data for Aboriginal and Torres Strait Islander groups in Australia can have serious policy implications.

These data have been used to inform burden of disease studies [70] and policy actions [242, 243, 250] and can lead to incorrect conclusions and unsatisfactory decisions. For example, in 2004-05, when self-reported data were collected to inform the development of the Closing the Gap targets [242], 42% of Aboriginal and Torres Strait Islander people aged fifteen years or over reported consuming the recommended daily intake for fruit and 10% reported consuming the recommended daily intake for vegetables. There were no significant differences between the proportion of Aboriginal and Torres Strait Islander (11%) and non- Indigenous people (13%) who reported meeting other relevant dietary recommendations; and the nutrition gap was deemed subsequently to be non-existent [146, 219]. However the questions asked had not been validated for application in Aboriginal and Torres Strait Islander groups, and it is unclear to what degree social desirability may have led to response bias. Self-reported data do not match the low levels of intake described consistently from application of more reliable quantitative methods. Further, self- reported fruit and vegetable intakes do not represent the entirety of nutrition and dietary issues affecting Aboriginal and Torres Strait Islander people. Hence the decision to effectively exclude nutrition from Closing the Gap was made on inaccurate data.

The lack of a collection of nationally co-ordinated growth data, or growth assessment and actions programs, for Aboriginal and Torres Strait Islander infants in Australia is a critical gap in the development of effective intervention policies. For example, owing to significant gaps in available data, Australia is not included in United Nations Children’s Fund (UNICEF) reports relevant to First Nations children, including The children left behind: a league table of inequality in child well-being in the world’s rich countries [285]. This report is important for many First Nations children who experience conditions near the bottom of the table, because it focuses attention on the need for resources and programs to close the equity gap [274].

Lack of data also makes it impossible to report against standard global nutrition indicators, particularly for infants and children [274]. In particular, few of the nutrition indicators in the Global nutrition report [5] can be reported for Australia; hence it is impossible to make meaningful international comparisons.

The need to develop reliable national nutrition and food security indicators and an effective monitoring and surveillance system has been highlighted repeatedly [220, 272]. This was identified in the NATSINSAP under the Key Action area: National food and nutrition information systems [81] re-iterated in resolutions from the 2008 National Nutrition Networks conference [233] and included in recommendations of the evidence-based scoping study for a new nutrition policy in Australia [220].

The limited monitoring of diet, nutrition and food supply and food security status, particularly among the Aboriginal and Torres Strait Islander population, but also across mainstream Australia, has restricted awareness of the significance of nutrition issues and concerted policy action to address these.

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Footnotes

1. The crystallized honey produced by larvae of psyllid bugs
2. Information on BMI and measuring weight and chronic disease risk is included in Box 3.
3. Information on BMI and measuring weight and chronic disease risk is included in Box 3.
4. Limitations associated with the NATSINPAS data collection methodology are outlined in Appendix 3
5. Discretionary foods and drinks are those not necessary for health, but high in saturated fat, added sugar, salt and/or alcohol; commonly called ‘junk’ foods and drinks
6. Free sugars include sugars added to food and drinks together with honey and fruit juice
7. When an electrical current is passed through the body, fatty tissue offers more resistance than lean tissue. The resistance to the flow of electricity is used to calculate the proportion of body fat in the individual.