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An introduction to socio-cultural aspects of Aboriginal and Torres Strait Islander nutrition for nutrition and dietetic students

Edwards, C. (2001). Nutrition Department, School of Public Health, Flinders University of South Australia.

Abstract

It is well known that the poor health experienced by many Aboriginal and Torres Strait Islander people is underpinned by complex reasons originating from their history after European settlement. It may be often overlooked by non-Indigenous dietitians/nutritionists - students and new graduates - that a barrier to the success of nutrition interventions is the lack of acknowledgment of this fact. An understanding and appreciation of Aboriginal and Torres Strait Islander culture is needed by non-Indigenous dietitians/nutritionists for the provision of mainstream nutrition services so that sustainable improvements in Indigenous nutrition and health can be achieved. Student dietitians at Flinders University of South Australia will be using this new resource in an attempt to raise cultural awareness and inform them of the available resources and existing strategies used to address Aboriginal and Torres Strait Islander nutrition. The resource presents information regarding the link between past history and present health; the importance of food; Indigenous dietary intake in urban, rural and remote locations; Aboriginal health workers; socio-cultural issues in dietetic program development and delivery; and directions in dietetic policy. It is intended to provide an appropriate introduction into the many varied and complex issues that compound the difficulty in improving nutrition and health for Aboriginal and Torres Strait Islander people. Indigenous health workers and education institutions are most welcome and urged to use this resource in an attempt raise cultural awareness among non-Indigenous dietitians/nutritionists and students. This document will be updated periodically.

Introduction

Aboriginal and Torres Strait Islander people suffer a much greater burden of ill health than any other sub-population in Australia. Poor nutrition is a major contributing factor, along with other factors such as poverty, sub-standard living conditions, geographical location, tobacco use, alcohol consumption, exposure to violence, and illicit drug and harmful substance use.¹ Major problem areas linked to poor nutrition are:

• low birth-weight infants
• poor growth rates for infants and children
• infection, diarrhoeal disease and iron-deficiency anaemia
• obesity
• type 2 diabetes
• cardiovascular disease
• renal disease

History

Numerous reports have highlighted the poor health status and socio-economic position of Aboriginal and Torres Strait Islander people in Australia. However, usually missing from such documents are the reasons for this from an Indigenous point of view.² Any effort to improve Aboriginal and Torres Strait Islander nutrition must start with an acknowledgment and understanding of the long-lasting effects of historical factors on Indigenous health today.² Two centuries of introduced disease, combined with today's lifestyle diseases and impoverished socioeconomic and environmental conditions, have had devastating, and all too often fatal, effects on Indigenous health.³ The Aboriginal and Torres Strait Islander population suffered from introduced disease that often proved fatal because of lack of immunity to introduced pathogens.⁴ Spiritual and psychological damage was inflicted upon the Indigenous population through their removal from ancestral lands, disbanding of families and herding into mission settlements and government reserves, whereby they lost much of their language, culture and identity.⁵

In 1788, Indigenous Australians were physically, socially and emotionally healthier than most Europeans of that time.⁴ The Aboriginal hunter-gatherer lifestyle meant there could be great variation in day-to-day food quality and quantity but that individuals would usually maintain a diet of subsistence, supplemented occasionally with times of feast after a successful hunt.⁶ Torres Strait Islanders were more involved in horticulture and trading than the Aboriginal people, supplementing their subsistence diet of garden foods with marine hunting.⁶

The traditional Aboriginal and Torres Strait Islander diet was low in energy, sugar and saturated fat, and high in micronutrients, protein, and low glycaemic index carbohydrate.⁷ After European settlement the diet was replaced eventually by one high in energy, saturated fat and sugar (for many, this was a consequence of food rationing with mainly flour, sugar, tea and meat). ^6,7 The methods of obtaining foods in the traditional diet were labour intensive involving much more energy expenditure than the relatively sedentary lifestyle experienced on missions, settlements and government reserves.⁶

The preparation and distribution of food for Indigenous Australians was strongly immersed in tradition. The action of obtaining food and the traditional food supply was central to the identity and harmony of the community.⁸ Eating had key social meanings in relationships, ceremonies and rights of passage.⁶ Provision of rations meant that responsibility for obtaining foods and the traditional meaning to many eating practices declined markedly. The situation didn't improve in later years, due to poor availability and choice of food even when financial allowances were provided for purchasing foodstuffs.⁶ Even today, quarantine regulations prevent the movement of ceremonial foods between islands in the Torres Strait.⁹

The general ill health of Indigenous Australians today is due to dispossession, marginalisation, and the creation of dependence upon various government departments and welfare services.⁴ A significant barrier to the success of nutrition intervention with Indigenous people is the lack of acknowledgment of these facts by health professionals.²

Dietary intake

The poor nutritional status of many contemporary Indigenous people is not merely a reflection of personal choice. It is dependent upon issues with food knowledge, availability and affordability (see Table 1). A self-perceived insecurity in their food supply revealed that 29% of Aboriginal and Torres Strait Islander people aged greater than 15 years, 'worried' or 'sometimes worried' about going without food.¹⁰ Aboriginal and Torres Strait Islander education is generally characterised by lower levels of achievement and retention rates, reflecting the widely held Indigenous belief that the education system is inappropriate to their needs.¹¹ Compared with non-Indigenous Australians, Indigenous people have lower income levels, with the majority of income being government benefits (including unemployment payments, work for the dole schemes and government pensions).¹² Dietary intake in the urban population is likely to be influenced also by factors typical of socio-economic disadvantage in the general Australian population.

Diet in remote and rural settings

Information about nutrition in remote areas comes largely from community studies rather than individual food-intake records. This provides information about the whole population of the area rather than the behaviours of individuals, and, as such, nutritional interventions that address any observable deficiencies may need to be population based or structural, rather than individual-based.¹³ Such studies give apparent per capita food and nutrient intake over a period of time and are really only possible when the community has a single food outlet, and food entering the community from store turnover figures or records of individual purchases are used. Assessment is not about adequacy of the diet, but rather possible adequacy of nutrients apparently available for consumption.¹⁴ When consumption of bush foods and alcohol aren't taken into account, underestimation may occur.

A review of remote community stores revealed a number of generalised poor nutritional practices (see Table 2).¹³ A consistent barrier to optimal nutrition in communities appears to be the short supply of dairy products and fresh fruit and vegetables, combined with high prices of such nutritious food because of transport and storage costs. Consumption of such foods relates directly to income, and may increase in the days immediately following payday. However, a diet of mainly bread and damper may be eaten for the remainder of the fortnight.¹² An analysis of the effects of retail store managers on two Arnhem Land Aboriginal communities found that they wield considerable power over remote food supplies and can be used as powerful allies in ascertaining Indigenous dietary intake.¹⁵

A review of 28 reports providing data on Indigenous diet, health and lifestyle showed that after westernisation, a high prevalence of type 2 diabetes, obesity, impaired glucose tolerance, hypertriglyceridaemia, hypertension and hyperinsulinaemia developed.¹⁶ Nutritional interventions involving adoption of a traditional hunter-gatherer diet, in addition to the increased physical activity and improved social factors, showed the potential to improve carbohydrate and lipid metabolism.¹⁶ An intervention study in the Minjilang community demonstrated how risk factors for non-communicable disease can be improved when the hunter-gatherer lifestyle is adapted to contemporary Aboriginal people living a healthier lifestyle with improved nutrition and environmental factors.¹⁷

A 'homelands' study of Aboriginal people in the Northern Territory who adopted a life of traditional culture with social interaction, high levels of physical activity and a more varied selection of food than the typical community store revealed that it led to numerous improved health indicators.¹⁸Contemporary westernised Aboriginal and Torres Strait Islander people are generally not able to revert to a traditional hunter-gatherer lifestyle - either because of lack of opportunity or because of personal preference.⁷ A more realistic and culturally viable alternative may be to adopt healthy western foods that are similar to hunter-gatherer foods (to reinforce traditional cultural concepts and food knowledge), in conjunction with increased physical activity.¹⁷ Nutrition education focussing on 'diet' and 'exercise' are not enough for they are commonly seen to be western health methods - programs need to be culturally appropriate and tailored individually for particular communities around Australia.⁶ It is also necessary for there to be a thorough knowledge of the food supply system so that strategies to improve nutrition are able to address the production, transportation and sale of food to remote and rural Indigenous communities.¹² Perhaps traditional food composition data would assist health professionals and Indigenous people in the development of appropriate dietary guidelines for particular communities or geographical areas.¹⁹

Diet in urban settings

Consumption of a high energy and high fat diet by adults who were malnourished during infancy and subject to disadvantage throughout life has been a large part of the Indigenous experience in the past and remains so today.²⁰ The majority of Indigenous food-intake studies have dealt with remote areas, but such data are of little use when dealing with nutritional issues for those in urban rural settings.¹³

A study using 24-hour recall in Kempsey, New South Wales indicated that dietary patterns were consistent with those of the wider society and suggested that dietary patterns and nutrient intakes of urban Aboriginal people are more similar to that of the general population than it is to remote living Aboriginal people.^12,21 A study of dietary habits in a capital city and country towns in south-east Australia revealed the frequency of consumption of take-away foods was higher for people of Aboriginal than European descent.²² Such differences were attributed to descent rather than rural or urban location, highlighting the need for action that is specific to Aboriginal and Torres Strait Islander people.²² In general, the limited data available on urban Indigenous nutrition indicate that the health outcomes are as poor as those in rural and remote areas.¹²

With urban Indigenous populations, dispersed living arrangements can cause great difficulty in identifying particular nutritional needs or obtaining family and community support.¹² Poor transportation, reduced access to supermarkets and easy access to take-away food outlets was identified as a key problem by the 'Food in Redfern Project', which noted a poor supply of supermarkets yet a considerable number of 'restaurants' for the largely Aboriginal population of the area.²³ Further issues in urban Indigenous nutrition are a lack of knowledge regarding culturally appropriate health and support services, advertising and 'junk food', and limited access and knowledge regarding traditional food and food sources.¹²

Aboriginal Health Workers

Aboriginal Health Workers (AHWs) are employed in mainstream health services and in the Aboriginal community-controlled health sector. AHWs can determine appropriate methods for nutrition education that take into account Indigenous teaching styles and cultural sensitivities.⁶ They have the ability to bridge the gap and create working relationships between mainstream health services, Indigenous communities and Aboriginal community-controlled health services.²⁴ They are often in great demand due to the high extent of ill heath and are required to deal with many issues of which nutrition is only one.²⁵ Non-Indigenous health professionals should be aware that training in nutrition and health is also available to Indigenous people in some states and territories, with courses such as the Certificate I in Health at Pundulmurra College in the Northern Territory.²⁶

Socio-cultural issues in dietetic program development and delivery

In 1989, the National Aboriginal Health Strategy Working Party emphasised the Indigenous holistic and social view of health:

An understanding of Aboriginal and Torres Strait Islander culture is essential for shaping the provision of mainstream nutrition services so that sustained improvement in health outcomes for Indigenous Australians can be achieved.²⁴ Nutrition programs need to oriented towards family and community, incorporating all adults, children, elders and key community members.¹² Aboriginal and Torres Strait Islander community members should be in partnership with Indigenous and non-Indigenous health professionals and organisations, for it is their skills, unique passion, and life experiences that can make nutrition programs acceptable for their community.²

Future directions in nutrition interventions can now be influenced by 'Nutrition in Aboriginal and Torres Strait Islander Peoples: An Information Paper' (Table 3).⁶ The lack of research investigating the effectiveness of Indigenous nutrition interventions meant there was insufficient evidence for this to be a guidelines document - instead it is presented as an information paper.⁶ Such recommendations should be made to work in concert with past National Health and Medical Research Council (NHMRC) Indigenous health promotion program recommendations (Table 4). Successful projects have demonstrated the ability to foster partnerships between Indigenous and non-Indigenous health professionals, and between health professionals and communities, which ultimately promotes respect and the use of each other's support, knowledge and skills.⁶

Socio-cultural issues and directions in dietetic policy

Australia's Food and Nutrition Policy (FNP) produced the 'Nutrition Education Manual for Aboriginal and Islander Communities - Sharing Good Tucker Stories', which involved consultation with Indigenous communities nationwide to collate 'stories' about how they dealt with food and nutrition issues.²⁷ Indigenous health workers and community leaders can now compare their community with others. The manual provides direction on planning and implementing a local public health food policy, awareness of legislation for nutrition education, intervention recommendations where food service facilities are inadequate, and guidelines on government liaison and funding grants.²⁷ Following on from the FNP, the Strategic Intergovernmental National Alliance (SIGNAL) developed the National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP) (Table 5) as a key component to the national public health nutrition strategy 'Eat Well Australia'.¹².Knowledge is shared in the areas of Indigenous community nutrition programs and approaches to best practice through Aboriginal and Torres Strait Islander nutrition networks, culminating in a 'Nutrition Networks' national conference that occurs every two years. For networks at a national, state or local level to be successful, there is a need for a multifaceted commitment from many sectors, including dietitians/nutritionists.²⁸

Conclusion

Healthier food choices need to be easy choices, because nutrition is difficult to achieve for many Aboriginal and Torres Strait Islander people due to circumstances outlined above. For Indigenous nutrition to improve dramatically, nutrition education alone is not enough. There is a need for historical acknowledgment, social action and structural change. Appropriate nutrition interventions must take into account nearly all aspects of life, and reduce dependency on government and non-Indigenous organisations.²⁹ Care must be taken not to 'blame the victim' like so many previous failed attempts, because no single nutrition program can solve problems in education, employment, housing or the other areas facing many contemporary Indigenous people.³⁰ Dietitians should not be seen as the gatekeepers of nutrition knowledge,³¹ but must be willing to build partnerships that truly accept the social capital of Aboriginal and Torres Strait Islander people. Communities need a voice in the development, implementation and evaluation of nutrition programs if they are to be culturally relevant and able to address the perceived needs of specific communities in urban, rural and remote localities. The latest efforts through NATSINSAP and the NHMRC are steps in the right direction and may provide guidance so that the huge differentials in health between Indigenous and non-Indigenous Australians can be narrowed, and, in time, eliminated.

Acknowledgements

Iris Lindemann, Kaye Mehta and Doug Ranson at the Nutrition Department, School of Public Health, Flinders University of South Australia, must be thanked for their support, encouragement and their inclusion of a version of this paper in the Bachelor of Nutrition and Dietetics and the Master of Nutrition and Dietetics curriculum.

References

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Last updated: 11 March, 2003