” The 2012-13 Health Survey identified that Indigenous adults were 1.6 times as likely to be obese as non-Indigenous Australians, with the prevalence increasing more rapidly in Aboriginal school-aged children.
Overweight and obesity in childhood are important predictors of adult adiposity, increasing the risk of developing a range of medical conditions, each of which is a major cause of morbidity, mortality and health expenditure.
While it is surprisingly clear what needs to be done to improve the health of Indigenous children, recent cuts to Indigenous preventative workforce and nutrition programs throughout Australia have severely reduced the capacity to respond.
Comprehensive primary health care is a key strategy for improving the health of Indigenous Australians and is an important platform from which to address complex health and social issues associated with obesity.
Closing the Gap, including the gap attributable to obesity, requires ensuring the ACCHS sector is resourced to deliver the full range of core services required under a comprehensive and culturally safe model of primary health care.
The effectiveness of ACCHSs has long been recognised, with many able to document better health outcomes than mainstream services for the communities they serve. “
Extract from NACCHO Network Submission to the Select Committee’s Obesity Epidemic in Australia Inquiry.
Download the full 15 Page submission HERE
” The Healthy Food Partnership is a mechanism for government, the public health sector and the food industry to cooperatively tackle obesity, encourage healthy eating and empower food manufacturers to make positive changes.
The Healthy Food Partnership’s Reformulation Working Group has developed draft reformulation targets for sodium, sugars and/or saturated fats, in 36 sub-categories of food. These food categories are amongst the highest contributors of sodium, sugars and saturated fat to Australian population level intakes.”
See Healthy Food Partnership Survey Part 2 Below
Introduction to NACCHO Network Sumission and selected extracts
The National Aboriginal Community Controlled Health Organisation (NACCHO) is the peak body representing 143 Aboriginal Community Controlled Health Services (ACCHSs) across Australia.
ACCHSs provide comprehensive primary health care to Aboriginal and Torres Strait Islander people through over 300 Aboriginal medical clinics throughout Australia.
ACCHSs deliver three million episodes of care to around 350,000 people each year, servicing over 47% of the Aboriginal population, with about one million episodes of care delivered in remote areas.
The Aboriginal Community Controlled Health Service (ACCHS) sector is the largest single employer of Indigenous people in the country, employing 6,000 staff, the majority of whom are Aboriginal or Torres Strait Islander.
The evidence that the ACCHS model of comprehensive primary health care delivers better outcomes than mainstream services for Aboriginal people is well established.
Without exception, where Aboriginal people and communities lead, define, design, control and deliver services and programs to their communities, they achieve improved outcomes.
The ACCHS model of care has its genesis in Aboriginal people’s right to self-determination, and is predicated on principles that incorporate a holistic, person-centred, whole-of-life, culturally secure approach.
The ACCHS principles of self-determination and community control remain central to wellbeing and sovereignty of Aboriginal people. Equipped with inequitable levels of funding and resources ,
ACCHSs continue to meet the ongoing challenges of addressing the burden of disease in Aboriginal communities.
The National Aboriginal Community Controlled Health Organisation (NACCHO) welcomes the opportunity to provide input into the Inquiry into the Obesity epidemic in Australia.
Aboriginal and Torres Strait Islander people represent approximately 3% of the Australian population yet are disproportionately over-represented on almost every indicium of social, health and wellbeing determinant.
Social determinants and historical factors such as intergenerational trauma, racism, social exclusion, and loss of land and culture are commonly recognised as causative factors for these disparities.
In 2008 the Council of Australian Governments (COAG) committed to addressing the health disparity between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians by adopting the Closing the Gap initiative. Whilst gaining some success in achieving convergence for some health indicators, wide health and wellbeing disparity still remains for both children and adults.
The life expectancy gap between Indigenous and non-Indigenous Australians remains 10.6 years for males and 9.5 years for females.
As a major contributor to morbidity and mortality among Indigenous Australians, obesity is estimated to account for 16% of the health gap between Aboriginal and Torres Strait Islander peoples and the total Australian population.
Comprehensive primary health care is a key strategy for improving the health of Indigenous Australians and is an important platform from which to address complex health and social issues associated with obesity.
Closing the Gap, including the gap attributable to obesity, requires ensuring the ACCHS sector is resourced to deliver the full range of core services required under a comprehensive and culturally safe model of primary health care. The effectiveness of ACCHSs has long been recognised, with many able to document better health outcomes than mainstream services for the communities they serve.
Combating the burden of obesity and its health effects for Indigenous Australians demands a strategic and coordinated whole-of-society approach at a national level by the Federal Government.
Without coordinated, sustained national action, efforts to improve the health status of Aboriginal children are likely to fail. In recognising the need to seriously address this critical and increasing gap in Indigenous health, NACCHO welcomes this inquiry and proposes the following recommendations:
- Government to work in partnership with NACCHO and the ACCHS sector to develop policies and plans that are responsive to the needs of Aboriginal communities
- A commitment to increase the understanding of Aboriginal and Torres Strait Islander peoples of the health significance of overweight and obesity, and facilitating access for these communities to resources which support healthy eating and physical activity
- Additional investment to build organisational capacity within the ACCHS sector and to increase the capacity of Aboriginal Health Promotion Officers to maintain a focus on public health initiatives
- Government to encourage professional support systems for, and assist Aboriginal Health Worker’s and other primary care workers to provide advice to adults and children about weight management as part of existing health checks and screening programs – this may be achieved by encouraging the MBS Aboriginal Health Check item to communicate more effectively the importance of physical activity, nutrition and weight management
- Fund the development of Aboriginal and Torres Strait Islander cultural awareness training for health care professionals covering care, education and information relating to food, physical activity, lifestyle choices and health service arrangements
- In understanding that health promotion is more difficult in regional and rural Australia, targeted funding should be dedicated to these areas to overcome the pervasive problems associated with distance
- A commitment to ongoing consultation with Aboriginal communities on what can be achieved at a local level to effectively promote healthy eating and physical activity for children
- Facilitate access for Aboriginal and Torres Strait Islander communities to resources which support lifestyle changes, including access to information, physical activity opportunities, and healthy food choices
- The prevalence of childhood obesity and the absence of culturally specific programs for Aboriginal and Torres Strait Islander people warrants further work in the development of culturally appropriate programs and tailored communication strategies alongside mainstream campaigns and messages
- Given the paucity of studies on Indigenous children, there is a need for further research on effective obesity prevention interventions for Indigenous families. This requires commitment to more detailed monitoring of young Indigenous children’s diets and their physical activity
- Government to work with the food industry and community stores to implement retail intervention strategies to positively influence access to and consumption of healthy food choices for Aboriginal and Torres Strait Islander communities
- Consider mechanisms to sustain programs on physical activity, nutrition and weight management that have proven effective
- Ensure significant participation of Aboriginal and Torres Strait Islander people in national surveys and evaluations by enhancing the sampling frame and applying culturally appropriate recruitment strategies
Evidence-based measures and interventions to prevent and reverse childhood obesity, including experiences from overseas jurisdictions
Evidence-based profiling of obesity and overweight in Indigenous Australian children has been poor, with very little known about the effectiveness of culturally adapted children’s interventions. Given the impact on health, finances and community, the need for better strategies and interventions to manage obesity are now being recognised by the entire health system.
Historically, initiatives have focused on nutrition or physical activity as separate entities and have shown modest effects. In recent years, global interventions considering the wider ‘obesogenic environment’ have been recommended, with policymakers and public health practitioners increasingly turning to evidence-based strategies to discover effective interventions to childhood obesity.
It is important to note, however, that the rapidly growing body of literature has meant many recommendations for childhood obesity have often relied on research that has not been systematically reviewed and focused more on assessing the internal validity of study results than on evaluating the external validity, feasibility or sustainability of intervention effects.
Experience in several countries has shown that successful obesity prevention during childhood can be achieved through a combination of population-based initiatives.li There is strong evidence for the effectiveness of school-based strategies, acting as an ideal setting for interventions to support healthy behaviours, and can also potentially reach most school age 9 children of diverse ethnic and socioeconomic groups. The Centre for Disease Control and Prevention (CDC) recommends a curriculum that is culturally appropriate and a school environment that reflects the culture within the community by demonstrating cultural awareness in healthy eating and physical activity practices.l
Examples of school-based strategies include policies that limit student access to foods and beverages that are high in fats and sugar, contributing to decreased consumption during the school dayliii, and efforts to increase physical activity leading to a lowered body mass indexliv and improved cognitive abilities,lv especially in younger children. An evaluation of a school-based health education program for urban Indigenous youth found compromising results in physical activity, breakfast intake and fruit and vegetable consumption, all of which are core components of healthy weight management.lvi
Studies have examined the effectiveness of culturally specific versions of programs to tackle obesity, including a US study comparing a mainstream program with a culturally adapted version. Findings were that cultural adaptations improved recruitment and retention numbers, with the authors recommending that to improve program design, ethnic communities and organisations should be approached to collaborate with researchers in design, modifications, recruitment techniques, implementation, evaluation and interpretation of results.lvii
A 2013 Canadian pilot evaluation of a whole-school health promotion program, Healthy Buddies, involved researchers consulting Aboriginal community members about how the program could be more effective, sustainable and culturally appropriate, resulting in a new version called Healthy Buddies – First Nations. Prior to implementation, communities were able to review the program and tailor its cultural appropriateness. Lesson content and visual aids were amended to resemble Aboriginal children, as well as Aboriginal food and activities.lviii In promoting social responsibility through the buddy system, the program showed a significant lowering in BMI and waist circumference and was considered particularly important for remote communities.
Systematic and evidence-based reviews have suggested promise in tailoring programs to be more culturally appropriate for specific ethnic and culturally diverse groups. The 2014 Global Nutrition Report, which examined the limited access to supermarkets and a reliance on fast-food as contributing to the growing prevalence of obesity in American Indian communities, recommended that interventions need to be multi-faceted, culturally sensitive, grounded in cultural traditions, and developed with full participation of American Indian communities.lix
Similar recommendations were made in a review by Toronto Public Health, identifying that interventions targeting children from low socioeconomic or culturally diverse backgrounds can positively impact on physical activity levels and dietary intake. This highlights the need to consider focusing on specific cultural backgrounds, like Indigenous Australians, when planning obesity prevention interventions to achieve better outcomes.
The role of the food industry in contributing to poor diets and childhood obesity in Australia
Improving the access to and availability of nutritious food is a vital step to combating the prevalence of obesity. Indigenous people living in rural and remote areas in particular face significant barriers in accessing nutritious and affordable food.
The level and composition of food intake is influenced by socio-economic status, high prices, poor quality fruit and vegetables in community stores, and unavailability of many nutritious foods.lxi This is indeed exacerbated by the exposure to high levels of unhealthy food marketing across a range of media. 10
The ubiquitous marketing of unhealthy food creates a negative food culture, undermining nutrition recommendations.
Substantial research documents the extensiveness and persuasive nature of food marketing in Australia; importantly, the vast majority of all food and drink marketing, regardless of medium or setting, is for food and drinks high in fat, sugar and/or salt.lxii Australian children are exposed to high levels of unhealthy food marketing through a range of mediums, including sponsorship arrangements with children’s sport. With research identifying a logical sequence of effects linking food promotion to individual-level weight outcomes,lxiii it is clear that food marketing influences children’s attitudes and subsequent food consumption.
Australia’s National Preventative Health Taskforce has highlighted the importance of restricting inappropriate marketing of unhealthy food and beverages to children as a cost-effective obesity prevention strategy.lxiv Clear affirmative action in Australia to such marketing has been lacking to date, compounding the need for Government to explore options for regulating the production, marketing and sale of energy-dense and nutrient-poor products to reduce consumption.
Research has shown that the prevalence of obesity increases and consumption of fruit and vegetables decreases with increasing distance to grocery stores and supermarketslxv and a higher density of convenience stores and take-away food outlets.lxvi Cost is also a major issue, with the price of basic healthy foods increased by 50% or more in rural and remote areas where there is a higher proportion of Indigenous residents compared to non-Indigenous residents than in urban areas.lxvii The purchasing behaviour of children is particularly sensitive to price, and can have significant effects over time.
Foods of better nutritional choice, including fresh fruits and vegetables, are often expensive due to transportation and overhead costs, or only minimally available.lxviii Comparatively, takeaway and convenience food, often energy-dense and high in fat or sugar, are less affected by cost and availability.
A study of intake of six remote Aboriginal communities, based on store turnover, found that intake of energy, fat and sugar was excessive, with fatty meats making the largest contribution to fat intake.lxx Compared with national data, intake of sweet and carbonated beverages and sugar was much higher in these communities, with the proportion of energy derived from refined sugars approximately four times the recommended intake.
Recent evidence from Mexico indicates that implementing health-related taxes on sugary drinks and on ‘junk’ food can decrease purchase of these foods and drinks.lxxi A recent Australian study predicted that increasing the price of sugary drinks by 20% could reduce consumption by 12.6%.lxxii Revenue raised by such a measure could be directed to an evaluation of effectiveness and in the longer term be used to subsidise and market healthy food choices as well as promotion of physical activity.
It is imperative that all of these interventions to promote healthy eating should have community-ownership and not undermine the cultural importance of family social events, the role of Elders, or traditional preferences for some food. Food supply in Indigenous communities needs to ensure healthy, good quality foods are available at affordable prices.
It is widely understood that many Aboriginal and Torres Strait Islander people, predominantly children, are at high-risk of ill-health due to overweight and obesity. This is likely to lead to a widening gap in health outcomes for Indigenous Australians if prevention efforts are not improved. Despite the identified health and economic gains which can be achieved by using a social determinants and culturally appropriate approach, Australia is yet to embed such thinking in health policy.
Policy in isolation will not solve the epidemic of childhood obesity for Indigenous children. What is required, is urgent action to address poverty, education, unemployment and housing, all of which are factors that shape a child’s ability to engage with healthy behaviours. There also needs to be close ongoing national monitoring through the collection of comparable data; more detailed monitoring of the composition of young Indigenous children’s diets and physical activity is necessary to determine whether patterns are changing in response to interventions.
Undeniably, strategic investment is needed to implement population-based childhood obesity prevention programs which are effective and also culturally appropriate, evidence-based, easily understood, action-oriented and motivating. Interventions must be positioned within broad strategies addressing the continuing social and economic disadvantages that many Indigenous people experience and need to have an emphasis on training community-based health workers, particularly in the ACCHS sector who are best placed to respond to the increasing rates of obesity and associated health concerns for Aboriginal and Torres Strait Islander people.
The ACCH sector has a central role in promoting and improving health outcomes for Indigenous people yet requires additional targeted funding and resources to implement new initiatives, including intervention, education, and research to encourage physical activity and healthy nutrition. Indeed, multifaceted strategies involving the public, private and ACCHS sector, along with community participation and government support, are required to gradually reverse this trend.
NACCHO and its Affiliates in each State and Territory appreciate the opportunity to make this submission on behalf of our member services. With circumstances unimproved after years of policy approaches, the need remains to overturn the prevalence of overweight and obesity of Indigenous people. There needs to be a commitment at all levels of government in terms of funding, policy development, and support for the implementation of culturally appropriate programs and services. There must be a recognition that self-determination of Aboriginal and Torres Strait Islander people will be the foundation of true progress.
NACCHO strongly recommend that Government engage in meaningful dialogue with NACCHO, NACCHO’s Affiliates in each State and Territory and ACCHSs in relation to the proposals canvassed in this response; and work in partnership to address the significant prevalence of obesity in Aboriginal and Torres Strait Islander people, especially children
Part 2 Overview Healthy Food Partnership Survey