The Australian Indigenous HealthInfoNet rolled out its landmark annual Overview this week, offering a comprehensive snapshot of the health and wellbeing of Aboriginal and Torres Strait Islander people.
Happily, it reported a decline in the death rate and closing of the gap on this measure as well as a significant drop in infant mortality.
The Overview also examined factors contributing to health, including nutrition and body weight. Some statistics of note include:
- dietary risks contribute 9.7% to the total burden of disease for Aboriginal people
- 69% of Aboriginal and Torres Strait Islander people are considered overweight (29%) or obese (40%); among children this is 30% (20% overweight, 10% obese)
- 54% of Indigenous Australians meet the daily recommended serves of fruit; only 8% meet the daily recommended serves of vegetables
- both measures are lower in remote communities compared with urban areas and intake is far more likely to be inadequate among the unemployed and those who did not finish school
- on average, Aboriginal and Torres Strait Islander people consume 41% of their daily energy in the form of discretionary foods — 8.8% as cereal-based products (cakes, biscuits & pastries) and 6.9% as non-alcoholic beverages (soft drinks)
- average daily sugar consumption is 111g — two-thirds (or the equivalent of 18tsp of white sugar) of which are free sugars from discretionary foods and beverages
- 22% of Aboriginal people reported running out of food and being unable to afford more in the past 12 months; 7% said they had run out and gone hungry — both were more prevalent in remote areas
In the latest issue of JournalWatch, Dr Melissa Stoneham takes a look at obesity in Australia’s remote Indigenous communities and the struggle to eat well against the odds.
Dr Melissa Stoneham writes:
After tobacco, overweight and obesity contributes heavily to the disease burden affecting Aboriginal and Torres Strait Islander Australians.
The 2015 ABS NATSINPAS survey identified that unhealthy discretionary (“junk”) foods that are high in salt, fat or sugar make up more than 41% of the energy intake of Aboriginal and Torres Strait Islanders in Australia. It also demonstrated that more than 20% of Aboriginal and Torres Strait Islanders report running out of food during the last 12 months and not being able to afford to buy more.
In 2013, a study of three remote Aboriginal communities found that people ate mostly processed foods high in sugar and salt and low in fruit and vegetables.
More specifically, it identified that one-quarter of total food expenditure in these communities was spent on non-alcoholic beverages, with just over 15% spent on sugar-sweetened soft drinks. As little as 2.2% of money spent went on fruit, and only 5.4% on vegetables.
Sugars contributed between 25.7% and 34.3% of energy, of which 71% was refined sugar and sugar-sweetened drinks.
Unfortunately these findings are not surprising. They indicate that access to affordable and nutritious food is an ongoing problem in many regional and remote Indigenous communities.
They reinforce that ‘empty calorie’ processed foods can be obtained at a relatively low price, compared with the high expense of fresh nutrient-rich foods (fruit, vegetables, lean meats, fish, dairy and whole-grain cereals). It is therefore not unexpected that cheap refined carbohydrates and processed foods make up the bulk of the diet available to most people living in remote Indigenous communities.
More importantly, it reinforces the devastating effects that Australian Aboriginal people have experienced due to the loss of access to their land, where traditional hunting and fishing would have historically taken place.
This loss has constrained access to nutritious and fresh sources of food, resulting in poor health and the replacement of healthy traditional foods with western-style foods that are energy-dense and brimming with ingredients such as refined sugar, salt and fat.
Do discounts deliver?
With food sovereignty being such an important determinant of good health for Aboriginal Australians, it was interesting to read an article in the Australian and New Zealand Journal of Public Health that aimed to retrospectively evaluate food price discounts in remote Aboriginal community stores.
Led by Megan Ferguson, who works with the Menzies School of Health Research in the Northern Territory, the article recognises that affordability is one of the key drivers in food choice generally but the cost of food is high and incomes are low in many Aboriginal communities.
The authors based their study on the premise that fruit and vegetable subsidies (i.e. price reduction or food at no cost) can have positive impacts on dietary intake, health outcomes and potential cost benefits, including in remote Aboriginal communities.
They identified a lack of evidence to support the design of pricing strategies, including type of instrument (e.g. subsidy or tax) and magnitude of the fiscal measure. Their study addressed these gaps.
Six Outback Stores which had been offering four food and beverage price discount strategies to improve access to nutritious and affordable food and support healthier food choices since 2010 were invited to participate in the study. The discounts applied to grocery items, fruit and vegetables (both loose and those with added freight) and diet soft drinks.
The six stores were deliberately selected to ensure representation and capture differences across central and northern Australia. Data were collected through key informant interviews, store observation and a retrospective analysis of point of sale data.
A total of 54 key informants were involved and included local store committee members, store managers and staff and customers. Most were Aboriginal (78%) and elderly (89%).
The interviews focused on recall and perceived impact of strategies on customer purchasing, perception of pricing strategies to improve access to nutritious and affordable food, and enablers and barriers to strategy implementation including methods recommended to communicate discounts. Following each interview, the research team reviewed and confirmed the written interview notes.
In-store observation consisted of a short list of factors including the fresh fruit and vegetable and beverage supply (range, quality, type of infrastructure, placement), operation of fruit and vegetable scales used at point-of-sale, promotion of strategies and price ticketing. All data were recorded in a field journal and reproduced in Word.
Retrospective electronic point-of-sale data were accessed through Outback Stores for each month from July 2009 to December 2010, including the product description, unit volume, quantity sold, and value of sales, for each participating store. Point-of-sale data were imported into a purpose built Access 2003 database, where food and beverage items were grouped and weights and volumes.
After analysis, no discernible impact of the discounts on groceries, fresh fruit and vegetables and diet soft-drinks on store sales or turnover was detected. However, the key informant interview data suggested that factors such as discount promotion and magnitude were barriers limiting the impact of the food pricing strategies.
Comments like ‘There’s no price on something that they are picking up. The benefit of cheaper is probably not immediately obvious to the customer’ and ‘They [i.e. customers] will buy the one 1.25 litre diet soft-drink under the dollar mark if that’s all they have’ reinforced these barriers and highlighted how ‘threshold value’ may influence purchasing decisions, particularly for drinks.
There was unanimous support from store managers, store staff, store committee members and customers for reducing the price of basic, nutritious, routinely purchased food and beverages, and the introduction of loose fruit and vegetables seemed to be appreciated.
Not surprisingly, the Store managers stressed the importance of adequate and functioning refrigeration and display units to stock groceries, fresh fruit and vegetables and drinks.
This is the first published evaluation of store-initiated strategies to effect price reduction on targeted lines in remote Aboriginal Australia, and readers are urged to visit the publication for additional detail.
Where to from here?
The recent Closing the Gap report identified that Australia is failing on six out of seven key measures. Life expectancy was one of the failed measures.
Reducing obesity amongst Australian Aboriginal populations and providing healthy, fresh and affordable foods to communities needs to be a whole-of-government priority.
There is no doubt that the environment is complex and, like the strategies we used for tobacco cessation, lowering obesity rates in Aboriginal communities requires a coherent, multi-level, multi-sector integrated approach supported by political will and resources.
Comments from the NT Chief Minister Michael Gunner reinforce this complexity: “Overcrowding in housing is a huge problem. Children who live in overcrowded houses are far less likely to attend school in the morning or to eat a healthy meal,”
This article acknowledges that the price of food influences consumption patterns, and that economic levers are a logical approach to help improve diets and health outcomes.
Yet the challenges are large and include, to name but a few:
- community stores being run as small businesses rather than as essential services, resulting in commercial pressures to sell cheap, unhealthy food at high profit margins;
- the cost and timetabling of transport;
- combating insidious advertising from big industry; and
- the lack of health hardware and basic refrigeration in communities
Most health professionals agree that to systematically reduce obesity in Australian Aboriginal communities, reform is needed and must include structural and regulatory changes to improve availability, affordability, accessibility and promotion of healthy food.
Few would argue that increased community capacity to prepare, cook and store healthy foods is also essential or that traditional foods should be integrated as often as possible.
Others have called for evidence-based economic interventions such as freight-subsidies, cross-subsidisation of healthy food and “fat taxes” to be trialed, or point to great potential in welfare reform and income management programs.
Whatever the solutions, a coordinated approach needs to be considered quickly in an attempt to reduce the 30% of Aboriginal kids and the 65% of adults who are overweight or obese.
Article – Food and beverage price discounts to improve health in remote Aboriginal communities: mixed method evaluation of a natural experiment. Megan Ferguson, Kerin O’Dea, Stacey Holden, Eddie Miles, Julie Brimblecombe. Australian and New Zealand Journal of Public Health; Vol 41, Issue 1; pages 32-37.
The Public Health Advocacy Institute WA (PHAIWA) JournalWatch service reviews 11 key public health journals on a monthly basis, providing a précis of articles that highlight key public health and advocacy related findings, with an emphasis on findings that can be readily translated into policy or practice.
The Journals reviewed include:
Australian & New Zealand Journal of Public Health (ANZJPH)
Journal of Public Health Policy (JPHP)
Health Promotion Journal of Australia (HPJA)
Medical Journal of Australia (MJA)
Environmental Health Perspectives (EHP)
Tobacco Control (TC)
American Journal of Public Health (AMJPH)
Health Promotion International (HPI)
American Journal of Preventive Medicine (AJPM)
Injury Prevention BMJ
These reviews are then emailed to all JournalWatch subscribers and are placed on the PHAIWA website. To subscribe click to Journal Watch click here.