Indigenous Australians Are Significantly
Indigenous Australians are significantly more disadvantaged than non-Indigenous Australians.1 Australian politicians introduced the Close the Gap Statement of Intent in 2008 with a commitment toward closing the gap of life expectancy between the Indigenous and non-Indigenous Australians. (2) Although significant gains have been achieved there are still health disparities; with the gap widening in some areas. (1)(3). Obesity and nutrition related illness amongst the Indigenous Australians is becoming an increasing burden on the public health system.4,5,6. This burden is largely reversible and avoidable. 7
The Indigenous diet contributes directly to their poor health. This results in a disproportionate number of chronic diseases being diagnosed in relatively young adults. (8)(5)(2). Cardiovascular disease (CVD), renal impairment and type 2 diabetes, can be up to 1.5 times more prevalent in the mortality and morbidity of Indigenous Australians. (9)(1)(10).
It is estimated that the incidence of CVD related mortality rates amongst age specific Indigenous Australians is 4 to 7 times more than those in the overall Australian population (11). CVD is the main cause of premature death of Indigenous Australian babies, and is responsible for over a quarter of the mortality difference between to the Indigenous versus non-Indigenous Australians (12). An intervention by the public health system to reduce the mortality rate would have a major impact on the communities and allow a better quality of life (1)(12).
Determinants of this Health Inequity
For the Indigenous population there are several risk factors for developing CVD. Some of the main risk factors are age, unhealthy lifestyle choice, genetics, obesity, insufficient exercise and poor diet(13)(12)(6). The Red Lotus Model of Health will be applied so a thorough understanding of the complex interplay between the aforementioned risk factors and the historical, geographic, socioeconomic and environmental factors can be gained. This will lead to an appreciation of how the determinants underpin the nutritional inadequacies that lead to the increased CVD burden on the Indigenous people (14)(15)(16).
Nutrition is a major contributor to maternal health, neonatal birth weight and subsequent growth and development. These factors can contribute to the lifelong health patterns of the individual (17)(14). Low neonatal birth weight among Indigenous babies has been identified as a risk factor for CVD and diabetes in adulthood18 (19)(20). Indigenous infants are twice as likely than non-Indigenous infants to be of low birth weight and have an increased susceptibility to nutritional and growth disorders throughout childhood (14)(8). During late adolescence Indigenous youth are 2 to 7 times more likely than non-Indigenous to develop an obesity related chronic disease such as CVD (21), It is thought that the early stages of the Indigenous individual’s life may have significant impact on the risk of developing CVD in later life. (8).
Historically Indigenous Australians were lean hunter-gatherers with a physically active lifestyle. They had a diet primarily composed of nutrient dense, low energy food which they sourced from the land (8)(14). Post 1788 however Indigenous family groups were displaced from their traditional homelands and rehoused into government settlements and church missions. Indigenous Australians gradually became dependent upon European food sources to feed themselves (14)(8). Men no longer hunted, women no longer gathered and they became reliant on processed food; often supplied in lieu of wages.(14) Over the next two centuries their diet altered to become a more highly refined food, high in energy density, low in nutrient value (14). By the 1970s the Indigenous population was experiencing increased rates of unemployment and the introduction of government benefits meant that, by the 1970s, inactivity and sedentary lifestyles, as well as alcohol abuse, were resulting in an emerging and increasing obesity and chronic disease incidence amongst these once robust people (14).
As well as a loss of their traditional diet, Indigenous Australians experienced a loss of their traditional lifestyle and culture leading to decreased social cohesion with long term, intergenerational consequences. The European settlement of Australia resulted in physical, psychological and social damage with increased social inequity and justice for the Indigenous population (3)(7).
The social inequity experienced by Indigenous individuals is a core determinant for their poor nutritional status (14)(15)(7). Low educational attainment, high unemployment rates, low income levels, high welfare dependency rates as well as substandard and overcrowded living conditions are known contributors to food insecurity (14)(7).
Low levels of education and income are significant determinants of Indigenous dietary inadequacy (14)(7). Research indicates that diet quality and chronic disease follow a socioeconomic gradient. The lower the educational attainment of the Individual and the lower the income level the more likely they are to consume a poor quality diet (22)(23). Fifty percent of all Indigenous Australians were reportedly in the twenty percent of house hold incomes (24). Low income is associated and contributes to poor nutrition by limiting the amount and quality of food consumed 25 (26)(27), because food choices are dictated by cost rather than nutritional value (27).This is particularly relevant in rural remote areas where due to the so called tyranny of distance, the availability of quality nutritious food is reduced and in general more expensive than less nutritional options. (24)(26)(14)(28).
Indigenous Australians are more likely than non-Indigenous Australians to experience the kind of environmental conditions which exacerbate food insecurity (12). The built environment that many Indigenous Australians live in present a barrier to adequate nutrition (14)(27). Overcrowding means that household facilities such as ovens, fridges and other appliances are simply not adequate to cater for the number of individuals who reside there (27)(29). Additionally inconsistent electricity supply, damaged surfaces and lack of general maintenance of facilities often leads to outsourcing food from other sources such as takeaway options (27)(14). Limited knowledge of nutrition, limited budget and a lack of familiarity with the food ingredients available has been indicated by Indigenous women as a barrier to the provision of nutritious meals (29).
The location of supermarkets and stores as well as the ability of individuals to access them has a direct influence on food security (27). Poor town planning, inadequate or non-existent public transport infrastructure may provide an obstacle for accessing to healthy food options (27). The cost of public transport if available may make accessing the service undesirable, especially in rural and remote settings (27). Fast food outlets are often more conveniently placed than supermarkets and fruit and vegetable outlets (27).
Solving this Health Injustice
To reduce the health disparity between Indigenous and non-Indigenous Australians a high priority needs to be placed upon improving the dietary habits of the Indigenous population (6). The 2009 Council of Australian Governments (COAG) National Strategy for Food Security in Remote Indigenous Communities stated that nutrition plays a significant role in reducing the chronic disease and life expectancy gap (30). Additionally improved nutrition will play a role in improving pregnancy outcomes, childhood health and educational attainment for Indigenous Australians (30,17,12) . Successful interventions designed to improve nutrition will require environmental level change in addition to programs that aim to alter individual behaviours (31). Because the underlying determinants of Indigenous nutrition are complex and multifactorial involving individual, social, economic and environmental aspects then a variety of culturally appropriate intervention strategies (29)(32) (29), aimed at simultaneously tackling as many of these aspects as possible, will be required to address this public health and social justice issue (33)(29).
It is important to engage the Indigenous community in the creation and implementation of these interventions. Community initiated and managed programmes are the most well received and appreciated by Indigenous communities (29). An intervention involving the establishment of a community horticulture programme are said to be a potential solution to food insecurity issues in disadvantaged and remote areas (27,34) . Success can be achieved through increasing access to fresh produce, potential to generate employment as well as generating income, promoting community pride as well as individual self-esteem, improving physical activity levels, reducing crime and building social capital (27)(34). The traditional hunter-gatherer lifestyle saw food integrated into all aspects of Indigenous life, enhancing their link to the land and their traditions; as well as being intimately linked to their sense of place, identity, and responsibility (32). Traditionally food played a significant role in Indigenous society; being used as a tool for teaching, for social interaction and social capital and held significance in ceremonial practices (29). Today Indigenous people still maintain strong ideological and spiritual connections to their traditional foods (29).
The public health initiative being proposed here is a ‘Bush Tucker’ Community Project. It is a multidisciplinary collaboration between Indigenous community Elders, Indigenous Health Care Workers and community members. The design and structure of the garden as well as what ‘Bush Tucker’ grown will proceed through an intensive consultative process with all interested parties. This traditional ‘Bush Tucker’ garden project which would be attached to a health centre or be in close proximity to the local school. The project aims to re-establishing traditional connections with their food as well as highlight the relationship between good nutrition practice and individual health. This will increase the desire to eat healthy food options while also improving accessibility to the healthy food.
Community Elders and other members of the Indigenous community can pass on traditional knowledge and skills relating to the Bush Tucker to relevant health care workers, school children, nutritionist and/or dieticians. This would provide an avenue for intergenerational learning and influence. The propagation, planting, growing, harvesting and preparation of the Bush Tucker as well as the health benefits of traditional and non-traditional foods would be shared by the community. The re-establishment of the oral traditions of storytelling can be facilitated around the traditional food practices ranging from preparation to cooking to consuming of the food. The garden can create an environment where learning, the asking of questions and the seeking of help can be undertaking in a culturally supportive and significant manner.
Aligned with the Bush Tucker Garden is a communal kitchen. This kitchen can provide clean safe food preparation and storage facilities. The kitchen will be used primarily for food preparation and cooking. The use of this facility will mirror the traditional way in which food was prepared. It allows for the transfer of traditional knowledge and cultural associations associated with food. It provides a socially cohesive environment, can serve a means to transfer knowledge from generation to generation and provides for an avenue of education programs targeted toward safe food handling and storage.
Important to the success of the ‘Bush Tucker’ garden project is the ownership taken by the Indigenous community. Ownership can be achieved not only by the inclusion in the design phase of the project but also by making the Indigenous community pay for the project. This can be achieved through a number of means other than financial contribution. One way to achieve ownership could be through employing members of the community to build and maintain the project. That way they are invested in the project and become advocates for its success and it increases the sustainability of the project.
This public health initiative aims to enable the Indigenous population to take control over the determinants of health affecting them (35); specifically determinants that result in the disproportionate incidence of CVD. This is in keeping with the core ideologies of the Ottawa Charter. The ‘Bush Tucker Community Project’ aligns with four of the five action areas of the charter (36). The acquisition of nutritional knowledge, traditional food production and preparation skills, building, design and maintenance skills and improved health literacy would build personal skills. Community action would be strengthened through the reintroduction of traditional practices, intergenerational learning, empowerment of Indigenous perspectives and ownership of the project and for the health benefits achieved (36). A supportive environment would result from realignment with traditional and culturally significant learning, the introduction of ‘reciprocal maintenance’(36), with everybody working toward a common goal; increased concern and care for the land and each other (35)(36). Re-orientating health services can be achieved by taking the education and learning processes away from the theoretical and the classrooms and making the lessons more practical and hands on and conducting them in a more receptive setting. Additionally the interaction between educators, health professions, community residents, children provides a foundation whereby trust can be engendered leading to greater inroads being made in reducing the health inequities and reducing the gap in life expectancy.
The Way Forward
Cardiovascular disease is a significant contributor to the life expectancy disparity, ‘the gap’, between Indigenous and non-Indigenous Australians (37)(1). The factors which contribute to an individual’s poor diet, poor food choices and risk of chronic disease development cannot be adequately addressed until the underlying socioeconomic and environmental determinants are addressed (14)(15)(31). Improved food security and diet quality are pre-requisites for reducing chronic disease incidence such as CVD and closing the life expectancy gap for Indigenous Australians. To address the health and social issues faced by Indigenous Australians and appreciation for the multifactorial nature of these issues needs to be taken into consideration. Therefore interventions need to adopt a multi-disciplinary, multi-faceted approach inclusive of the Indigenous input and which will target many of the social and environmental determinants of health (24) (31). Embracing collaborative approach between