Background
Food and health
The foods we eat have a major impact on our health and wellness. Healthy diets and foods can protect against chronic disease, and unhealthy diets and foods can cause or are associated with some chronic diseases. Fresh, unprocessed foods such as salads, vegetables, fruits and meats should form the foundation of our daily food intake.
Australian healthy eating guidelines
The Australian dietary guidelines provide an outline to healthy eating for healthy Australians.1 They were last published in 2013 and are currently being updated. The guidelines identify the following five food groups and make recommendations about daily consumption: lean meats and poultry, fish, eggs, tofu, nuts and seeds and legumes/beans; grain (cereal) foods, mostly wholegrain and/or high-fibre varieties; vegetables and legumes/beans; fruit; and milk, yoghurt, cheese and/or other alternatives, mostly reduced fat. Although the Australian dietary guidelines emphasise that ultra-processed foods should be limited, there are a considerable number of ultra-processed foods included in the five food groups.12 Ultra-processed foods make the highest dietary contribution to energy intake (calories) for people in Australia, accounting for 42% of energy intake, with the consumption of ultra-processed foods impacting negatively on the intake of non-ultra-processed foods and on all nutrients linked to chronic disease in Australia.12 However, dietary recommendations are written to provide guidance, and therefore form a starting point for nutrition therapy.13 It must be noted that the Australian dietary guidelines were designed for healthy Australians and do not apply to those who require specific dietary advice for a medical condition.14 In addition, although the Australian dietary guidelines are a helpful resource, limited studies that investigated nutrition for Aboriginal and Torres Strait Islander peoples have been included15 and following the guidelines has been reported to be largely unachievable for those on a low income, even within major cities.16,17 To achieve the greatest change over the long term, health professionals should help their patients select the dietary approach that best aligns with their preferences, values and treatment goals.13 This is especially important when working within Aboriginal and Torres Strait Islander communities, because food availability and cost can vary, and this will impact the choices patients make.
Building trusted relationships and providing cultural safety is important in discussions around food intake. Historical distrust of the health system and its role in the Stolen Generations remains an ongoing barrier to discussions on nutrition, particularly for children, with families concerned about judgement and potential impacts on child protection.
Health professionals need to be aware of racism, bias and discrimination, especially in the area of alcohol consumption. Excessive alcohol intake is often assumed to be a major problem within Aboriginal and Torres Strait Islander communities, yet Aboriginal and Torres Strait Islander people are more likely to abstain from alcohol.18 The amount of and regularity with which alcohol is consumed vary across individuals and communities (refer to Chapter 2: Healthy living and health risks, Alcohol).
Access
Access to healthy food is impacted by availability, affordability, resources to store and prepare food and knowledge about what is healthy food. Across Australia, many people live in an environment where ultra-processed foods are highly available, but also very inexpensive. In contrast, healthier foods are less accessible and often more expensive, being over 50% more expensive in some remote communities than in cities.19
The increased consumption of ultra-processed foods has negatively impacted the intake of fresh and minimally processed foods. This has led to an increase in calorie consumption because ultra-processed foods usually contain high amounts of fat, sugar and salt, making them very palatable and habit-forming.12,20 A study from the UK, which provided participants with three meals per day and compared unprocessed and ultra-processed foods, reported an excess of around 500 kcal/day for people eating a diet containing ultra-processed foods, with the extra calories coming from carbohydrates and fats.20 In another study, Lee et al investigated the affordability of healthy diets for people living in Sydney and Canberra and found that a healthy diet can be more affordable than the current diet for some people, but it remained unaffordable for those on a low income living in disadvantaged areas of the cities, and that it would be highly likely these families would be dealing with food insecurity.17 Particularly in remote communities, energy insecurity can have an impact on the ability of families to store food, which then requires the daily purchase of food at local stores, which are more expensive than supermarkets in larger towns. Season- and climate-related events, such as flooding, can also impact food and water security. Although many food affordability tools have been developed, few have provided a comparison on the cost of healthy foods versus current eating plans.19 This should be considered when providing dietary advice.
The availability of safe drinking water can also be an issue for some communities. Access to safe drinking water may not be guaranteed, particularly in regional and remote Aboriginal and Torres Strait Islander communities. Reports have identified a lack of testing and the presence of contamination to tap water in more than 400 remote or regional Aboriginal and Torres Strait Islander communities, and cost can be a barrier to access to potable (drinkable) water.21
Poor nutritional status is a modifiable risk factor for the prevention and management of many chronic diseases.22 A localised approach should be provided based on the opportunities and barriers in the region, rather than on race. A systematic review of qualitative research by Christidis et al2 reported a range of barriers to healthy eating for Aboriginal and Torres Strait Islander peoples, including interpersonal and institutional racism, the availability and marketing of junk (ultra-processed) food and disruptions to family and culture, as well as issues around food accessibility and affordability, housing conditions, food knowledge and cooking skills. Culture is integral to health and wellbeing, including when it comes to traditional foods; conversely, disconnection from traditional food systems is a barrier to good health.2 Racism is also a barrier to healthy eating and can occur when dealing with food store employees and healthcare providers.2 Junk foods are often given priority placement at eye level along shopping aisles, at the ends of each aisle and at checkouts. 2 Junk foods are also more likely to be discounted and promoted.2 Some families reside in houses that do not functionally support a healthy lifestyle.23
Although access to fresh foods may be more of an issue for people living in some regions, the number of people who do not meet the recommended daily intake of fruit and vegetables is similar between Aboriginal and Torres Strait Islander people and non-Indigenous Australians.5 In addition, sugar intake is higher for Aboriginal and Torres Strait Islander people living in non-remote areas than for those living in remote communities.5 Aboriginal and Torres Strait Islander peoples have other issues that increase susceptibility to poor nutrition, with 34% of the health gap being attributable to social determinants of health.24 These social determinants of health include racism, the increased availability of poo- quality foods, the accessibility and affordability of quality foods, housing conditions, health literacy and cooking skills.25 Comparatively, 19% of the health gap is attributable to ‘health risk factors’ that include the consumption of fruit and vegetables and levels of physical activity.24 For this reason, health programs that focus on nutrition education without addressing the social determinants of health will have limited impact.3
Culture and diet
Colonisation has impacted Aboriginal and Torres Strait Islander peoples’ health in many ways and, if health outcomes are to be improved, it is important health professionals understand the impact of colonisation.26 Ongoing colonisation has brought about a change from the traditional healthy diet to an energy-dense Westernised diet high in refined sugars and fat, which has resulted in increasing rates of chronic disease.2,3 Whole communities were moved off their land to expand European land tenure, which still, to this day, limits their ability to access traditional foods and increases food insecurity.27 This has also led to a loss of culture2 and knowledge of food systems.22 Culture is central to the health and wellbeing of Aboriginal and Torres Strait Islander peoples and although access to traditional foods was often limited, connecting to culture in this way has been reported to be associated with positive health and wellbeing.2
Prior to colonisation, the way Aboriginal and Torres Strait Islander people lived was very active with sophisticated agricultural and aquacultural practices28 that ensured the ongoing availability of food. Early reports indicate that Aboriginal and Torres Strait Islander peoples were lean and healthy, with little evidence of chronic diseases, such as type 2 diabetes and cardiovascular disease.29,30 With over 250 distinct language groups and broad cultural diversity, there was no one traditional diet. However, most regions reported a varied and nutrient-dense diet that was high in protein and fibre and low in refined carbohydrates.29 Although limited research has been completed on nutrition for Aboriginal and Torres Strait Islander peoples,15 research has shown that traditional foods may have a protective effect against modern health-related issues.29
Evidence of specific interventions
O’Dea reported on a seven-week intervention that took a strengths-based approach for Aboriginal people with type 2 diabetes.9 Fourteen Aboriginal participants were recruited from a community where people had access to traditional foods. Ten participants had type 2 diabetes (five women, five men) and four were euglycaemic (ie without diabetes; two women, two men). The average mean starting body mass index of those with type 2 diabetes was 27.2 kg/m². Participants followed a traditional lifestyle, which consisted of hunting and collecting their own foods at both coastal and inland locations, including beef, kangaroo, turtle, fish, crocodile, birds, fruits, vegetables and honey. Food intake was high in protein, which ranged from 50% to 80% of the daily dietary consumption of between 1100 and 1300 calories per day.2
The average weight loss over the seven-week period of the intervention was 8 kg, with body mass index decreasing from 27.2 to 24.5 kg/m². Fasting plasma glucose concentrations decreased from 11.6 mmol/L at baseline to 6.6 mmol/L at Week 7. There were also improvements in glucose tolerance and glucose removal after glucose ingestion, and a significant reduction in the postprandial rise in glucose concentration in the glucose tolerance test. In addition, fasting insulin levels and fasting plasma triglycerides decreased significantly. Fasting glucose, insulin and triglyceride concentrations reduced to normal or near normal levels.2
A more recent study by Power et al reported on a strengths-based lifestyle intervention in an urban setting for Aboriginal people with diabetes.4 In that study, 22 participants were recruited into the program, 16 with a diagnosis of type 2 diabetes, four with prediabetes, and one with type 1 diabetes. The 10-week lifestyle intervention provided dietary and physical activity guidance and support. The meal plan consisted primarily of fresh unprocessed foods, reduced carbohydrates and calorie restriction (~1200 kcal/day). The exercise program began with walking within the individual’s limitations and averaged 30 minutes on most days. Participants were encouraged to include other physical activities that they enjoyed. There were weekly meetings where weight, random blood glucose and blood pressure were measured. Educational videos were provided across the 10 weeks via email, and daily motivational videos were sent via SMS. Health literacy was addressed through videos and the use of simple language. The aims of the program were to achieve mean HbA1c <7%, weight loss of 5–10% of initial body weight, systolic blood pressure <140 mmHg and diastolic blood pressure <95 mmHg, a reduction in medications and enhanced self-management. Qualitative interviews were conducted at the completion of the program with 16 participants.
At the completion of the 10-week intervention, mean HbA1c had been reduced from 8.14% to 6.29% (–1.68%). The mean weight loss was 7.46 kg (6.6% of starting body weight). Systolic blood pressure was reduced by 8.88 mmHg and diastolic blood was reduced by 4.69 mmHg.4
Participants reported health benefits that extended beyond weight loss and improvements in HbA1c, such as a feeling of belonging and confidence in being able to improve their health and wellbeing.4
What health services can do
In order to be effective, Aboriginal and Torres Strait Islander people need to be included in the design and implementation of strategies aiming to improve nutritional health outcomes.31 The health professional understands the health information and the patient understands their and their family’s realities, lived experiences, needs and aspirations. Trust and respect for each other’s contribution is required to design strategies that can be effective over the long term.32 Moving away from the deficit narrative that has formed prior policy and research and moving to a strengths-based approach will improve health outcomes,33 although to date this approach has not been widely adopted with regard to nutrition.34
A strengths-based approach in health requires the use of a framework that looks to what Aboriginal and Torres Strait Islander people can achieve, using their strengths and assets, such as knowledge, skills, networks, extended family and cultural identity.33 Health professionals should explain the situation from a health perspective, and provide a range of options on strategies to improve it. The patient should then be encouraged to choose which option would best suit them and provide strategies to help them achieve their health goals. To ensure the patient understands what it is they need to do, the health professional should ask the patient to explain in detail what they plan on eating across the course of the day. This will provide the health professional with the opportunity to identify any gaps in the patient’s understanding of what they need to do.
Implementing healthy eating habits can be difficult for some people. They may not have support at home, they may need to consider others living in the household when preparing meals, and cool storage of fresh foods may not be possible. These issues should be considered when providing advice, along with the previously mentioned barriers, such as cost and access to fresh foods (see Boxes 1–3).
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Box 1. Practical advice based on Guidelines 1–3 in the Australian dietary guidelines1
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Guideline 1
To achieve and maintain a healthy weight, be physically active and choose amounts of nutritious food and drinks to meet your energy needs |
This can be achieved by walking for 30–60 min/day and avoiding long periods of sedentary behaviours. For those who cannot walk for that long due to injury or a low level of fitness, begin at a slow pace, on a flat surface, for a period of time that is comfortable. Slightly increase the duration every one to two weeks |
| Eat three to five times per day, but limit your portions to sustain you, rather than fill you |
Guideline 2
Enjoy a wide variety of nutritious foods from the five food groups every day |
Eat a wide variety of fresh foods and ensure you are getting sufficient amounts of vegetables and protein |
| Traditional foods can form a part of a nutritious, healthy diet1 |
Guideline 3
Limit intake of foods containing saturated fat, added salt, added sugars and alcohol |
Limit the intake of ultra-processed foods because they often contain high amounts of saturated fat, salt and sugar.1 Most snacks and meal should consist of fresh, unprocessed foods, such as vegetables, fruits and meat.1 Meat alternatives may be substituted for those avoiding meat, but low-/non-processed protein sources are best |
| Limit alcohol to one to two days per week and avoid excessive intake on these days1 |
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Box 2. Guide to healthy eatingA
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| Most people need to eat and drink MORE |
Vegetables and fruit: particularly green, orange and red vegetables such as broccoli, carrots, capsicum and sweet potatoes; leafy vegetables like spinach; and legumes/beans like lentils |
| Reduced-fat milk, yoghurt and cheese varieties (reduced fat milks are not suitable as a main milk drink for children aged under two years) |
| Lean meats and poultry, fish, eggs, nuts and seeds (note many Australian men would benefit from eating less red meat) |
| Water |
| Most people need to eat and drink LESS |
Meat pies, sausage rolls and fried hot chips |
| Potato crisps, savoury snacks, biscuits and crackers |
| Cakes, muffins, sweet biscuits and muesli bars, confectionary (lollies), ice-cream and desserts |
| Processed meats like salami, bacon and sausages |
| Cream and butter |
| Jam and honey |
| Soft drinks, cordial, energy drinks and sports drinks |
| Wine, beer and spirits |
| AAdapted from the Australian dietary guidelines summary.35 |
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Box 3. Tips and advice for patients
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Access to healthier food options
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- If the cost of fresh foods is an issue, encourage patients to eat foods that are in season. This will usually mean they are in abundance and will keep the cost of foods down.1
- In some communities, food banks, fresh food markets or roadside fresh produce stores can provide a great opportunity for purchasing fresh foods.
- When shopping at a supermarket, the healthier foods are usually in the outside aisles, so encourage patients to select most of their foods from these areas.
- Frozen or canned vegetables are an ideal option for preparing healthy meals when fresh foods are not available, but canned foods do undergo some processing.1
- Traditional foods should be encouraged because these can often provide an inexpensive, seasonal and nutritious option that combines culture with good health.36 Traditional foods also require more energy to collect. Traditional foods will vary from each Aboriginal or Torres Strait Islander nation; coastal communities may rely more on seafood, whereas inland communities will enjoy marsupials, birds and fish from the local waterways. All communities will traditionally also have a range of plant-based foods. Unfortunately, access to lands to hunt and collect these can be limited but, if it is an option, it should be encouraged.
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Food choices
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- Considerations need to be made for those who may not have the confidence in preparing fresh foods.4 They may not have been raised eating the range of ingredients we have available today or have the taste for it right away. Discuss which fresh ingredients they do like, and encourage them to Google recipes that include these ingredients. Many families are raised on curries, soups and stir fries, and this could be a good starting point. Slow cookers, steamers and air fryers are also good options for simple ways of preparing foods.
- Options must suit the whole family.4 It is difficult for a person to improve their own eating habits if it does not fit in with the other people they are eating with. This can be especially difficult if their children are picky eaters. Encourage them to discuss potential recipes with family members to ensure buy-in.
- Social activities can often revolve around meals, so considerations should be given for inexpensive and accessible options for family gatherings.
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Drinks
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- The consumption of drinks contributes to the health of an individual.37 Water should be encouraged as the primary source of hydration, with soft/sugary drinks, alcohol and fruit juices being supplemental.
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