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Review of nutrition and growth among Indigenous peoples

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Introduction

Nutrition is the study of food and how our bodies use the nutrients in food.

Nutrients are parts of food that are important to help our bodies function. The main nutrients found in foods are:

Good nutrition (getting enough of the right nutrients) is necessary for growth, and for physical and mental health. Proteins, fats and carbohydrates are used by the body in everyday general activities, as well as assisting our bodies to recover from injuries or illness.

Vitamins and minerals are required by the body's cells and organs, and lack of particular vitamins or minerals can lead to illness or disease. Poor nutrition (not getting the right mix of nutrients) increases the risk of a person getting diseases such as:

It is difficult to know how much poor nutrition is involved in the development of these diseases (whether poor nutrition has a large part or a small part), because there are so many other factors that play a part in the development of disease. These other factors include behaviour, the environment in which a person lives, and what genes a person has inherited from his or her parents.

For heart disease the nutritional factors that are known to play a part in the development of the disease include:

Certain behaviours that are known to increase the risk of a person getting these diseases are:

In the Indigenous population the most common nutrition-related diseases are:

In the past, as hunter-gatherers, Indigenous people needed to work together and be physically active when finding food. Changing to a European diet and lifestyle has changed all this, and has caused problems for many Indigenous people with healthy, affordable food often being difficult to get.

A short history of Indigenous nutrition

The hunter-gatherer method was the way of life of all humans until about 12,000 years ago, when human groups started to experiment with growing plants.

Indigenous groups in Australia lived in many different climates and locations, varying from tropical to more moderate climates, from coastal to central areas. Some of them were nomads, moving regularly from one place to another to find food. Those living in coastal areas were less likely to move around because food was always plentiful.

Indigenous hunter-gatherers ate local plants, animals and fish. The men mostly hunted the large animals, while the women collected the small animals and plants. In places where there was plenty of food and water large groups might camp for weeks or months before moving on.

There is very little known about the health of Indigenous people before Europeans came to Australia, but it is understood that they were very healthy, fit and strong. The traditional diet was high in protein, complex carbohydrates (those that are digested slowly) and nutrients, and low in sugars. The types of foods that were eaten depended a lot on where the people were living and the time of year.

Torres Strait Islander people generally ate more seafood than the Aboriginal people, because seafood was so easy to collect and was always available. They were very knowledgeable about the sea, about the feeding patterns of the animals, tidal movements and such like. The foods available in the Torres Strait varied between the islands, and the Islanders depended partly on simple forms of agriculture and trade.

Indigenous nutrition after 1788

The hunter-gatherer lifestyle of Indigenous people changed after the arrival of Europeans in Australia in 1788. When their traditional lands were taken over by farmers and graziers, many Indigenous people were forced to live in settlements and to get food and other necessities from the Europeans.

The numbers of Indigenous people decreased after the arrival of the Europeans because of a number of factors: violence; diseases brought from Europe; and malnutrition (not enough healthy food).

Many Indigenous groups settled on cattle stations, government settlements or missions (run by religious groups) where they ate mostly European food. This was before 1969 when Indigenous people did not receive all their pay as cash. Food was provided in exchange for work and there was often no choice in the food received. Some of these foods were highly processed (manufactured) so they could survive long periods of transport and storage, but they were often very high in fat, sugar and salt. When they did not receive enough food from their bosses, the Indigenous people would collect bush foods.

Communal feeding (in big groups) often occurred in these situations. One result of this was that mothers had less responsibility for feeding their own children and lost a lot of the knowledge they had about food and feeding.

This dependence on the European bosses gradually led to most Indigenous people converting to a ‘Western' diet, with much less physical activity involved. Women no longer needed to gather and prepare the food and spent more time sitting around camps and settlements. In the 1970s some changes occurred that led to big changes in men's lifestyles as well:

The result of this was that many of the men were no longer working, leading to less physical activity, an increase in energy intake (food and alcohol), and continued lack of nutritious foods.

The fast rate of change of the Indigenous diet has increased the risk of diet-related diseases such as obesity and non-insulin-dependent diabetes (also called type 2 diabetes or adult-onset diabetes). The change has been from a fibre-rich, high protein, low-saturated-fat traditional diet to one high in refined carbohydrates (like white flour where most of the nutrients have been removed during processing) and saturated fats (which come from animal foods). Other groups that have been through similar rapid lifestyle changes include the Pima Indians and Native Americans. They too have seen an increase in the risk of these diseases.

Current nutrition and growth trends

Growth in the womb

The effects of a mother's diet and nutrition when she is pregnant can have lifelong effects on her child.

Of particular concern is babies who do not weigh very much when they are born (known as ‘low birthweight'). Low birthweight (below 2500 grams) can be caused by several factors happening to the mother, either separately or combined:

A baby who has a low birthweight is at a higher risk of childhood death and many health problems.

Growth in infancy and early childhood

Healthy growth before birth and after birth depends on:

Factors that can prevent or slow down growth:

Birthweights

An Australian study done in 2005 showed that the average weight of babies born to Indigenous mothers was lower than that of non-Indigenous mothers (3158 grams for Indigenous babies and 3375 grams for non-Indigenous babies). It also found that Indigenous mothers are more likely to have low birthweight babies than non-Indigenous mothers.

Mother's nutrition

A study was done in Darwin between 1987 and 1990 which looked at birthweights of 503 babies born to Aboriginal mothers. The study looked at the babies of mothers who were underweight, that is had a body mass index (BMI) of less than 18.5 (see box for an explanation of BMI). It found that:

Table 1: How to calculate BMI
Box: How to calculate BMI
Source: WHO Consultation on Obesity (2000)
  • Body mass index (or BMI) is the measure used to calculate body weights. BMI can tell you whether a person is under weight, has a healthy weight, is overweight or is obese.
  • To calculate BMI you need to know a person’s weight (in kilograms) and height (in metres).
    The weight is divided by the height squared (the number times itself). For example to calculate the BMI of a woman who weighs 65 kilograms and is 1.70 metres tall: 65 (weight in kilograms) divided by 1.70 x 1.70 (height squared) = 22.5
As seen below a BMI of 22.5 is considered ‘normal’.
Classification of BMI and risk of disease
Classification BMI Disease risk
Underweight Less than 18.50 Low
Normal 18.50–24.99 Average
Overweight 25.00–29.99 Increased
Obese 30.00 or more Further increased

Smoking

Smoking also has a big impact on birthweight. From 2001-2004, babies born to Indigenous women who smoked were, on average, lighter than babies born to Indigenous women who did not smoke (3037 grams compared with 3290 grams). Almost double the number of women who smoked had low birthweight babies compared to women who didn't smoke, in both Indigenous and non-Indigenous women.

How we measure growth and weight in children

Measuring a child's growth is an important way to measure their overall health and development.

Charts of children's heights and weights have been produced by the World Health Organisation (WHO) and the US Centre for Disease Control. These can be used to follow a child's growth and weight over years to see whether they are developing as expected.

When a child does not develop as well as expected by the chart, this is probably because of poor nutrition and/or living conditions. The child can then be identified for treatment to improve their nutrition, which leads to better growth and improved long-term health.

Growth charts are developed by getting information on heights and weights of lots of children at different ages. Information from whole populations can be used to work out the ‘usual' weight or height of children at a particular age. There are separate charts for boys and girls because they grow at different rates. Individual children can then have their weight and height compared to these charts to see if they are less than, the same as, or greater than the charts.

The WHO has also recently developed BMI charts for school children and teenagers.

Breastfeeding

Introduction

For newborn babies and small children, breast milk is the best food they can have:

For mothers the advantages of breastfeeding are:

Healthy babies are more likely to grow into healthy adults, so encouraging good health early, through breastfeeding, is a wise thing to do.

The Australian Dietary Guidelines for children and adolescents has ‘encourage and support breastfeeding' at the top of its list of guidelines. The recommendations are that babies should be breastfed only (no food) for the first six months, with breastfeeding continuing to 12 months or beyond along with solid food.

Breastfeeding among Indigenous people

Before the arrival of Europeans, all Indigenous mothers breastfed their babies. Babies would be carried and fed while their mothers gathered food. If necessary, other women who were also breastfeeding could feed a child whose mother could not feed for some reason. The traditional way was to breastfeed for up to four years, sometimes longer, gradually introducing nutritious bush foods.

These days Indigenous people have lower breastfeeding rates than non-Indigenous people (less Indigenous people breastfeed their babies), except for those still living in remote areas.

An Australian survey in 2004-05 of breastfeeding showed:

There are a lot of reasons why mothers give up breastfeeding or choose not to in the first place:

With Indigenous mothers, studies in Victoria and the Northern Territory found that the most common reasons for stopping breastfeeding were:

Other reasons (not so common):

When a child is being weaned, the risk increases of them developing infections and malnutrition. In some Indigenous communities where living conditions are not very hygienic or there is a lot of contamination (e.g. rubbish lying around, food is not refrigerated), the risk for a child is much greater than in other communities:

For a long time the Australian government has recognised that there needs to be a strategy to encourage mothers to breastfeed for longer, and to promote appropriate foods for Indigenous infants. In 1997 two reports were produced on this topic. Areas that were identified as needing special attention were:

More recently (in 2007) the Australian Parliament had an inquiry into breastfeeding, with special attention on breastfeeding by Indigenous mothers. The recommendations included:

Growth of Indigenous infants and young children

In the 1960s it was accepted that Indigenous infants and young children did not show the same patterns of growth as most other Australian children:

For a long time it was believed that this growth pattern was genetic, that it was the way all Indigenous babies grew. Studies carried out in the 1980s, however, showed that Indigenous children brought up in good living conditions showed similar growth patterns to non-Indigenous Australian children.

Studies in the 1970s and 1980s identified this same pattern of growth in Indigenous children in rural and remote areas of the Northern Territory and Western Australia.

Around this time, however, health workers in the Kimberley began to notice improvements:

In 1987 the Aboriginal Birth Cohort study began in the Top End in the Northern Territory. The aim was to collect information (height, weight, and health information) on Indigenous babies born in NT from 1987 to 1989 and to continue to collect information over a long period of time (after 11 years, 20 years and 25 years). This type of study, known as a longitudinal study, allows the researchers to investigate causes of diseases and other health issues.

Results from this study in 1987-1989 showed a similar pattern of growth for Indigenous babies as was seen in the Kimberly, but after 11 years the growth of urban-dwelling children had improved while that of the remote children had not.

The results of this study led the government in the 1990s to set up the Growth Assessment and Action (GAA) program. The GAA keeps track of the growth of Indigenous children up to five years of age in about 80 remote communities in NT and takes action if the growth rate seems to be falling.

The most recent review by the GAA in April 2007 measured the growth of 3000 children aged less than five years (out of a total number of 4064 children), living in rural and remote communities. The results showed:

According to the international organisation UNICEF (the United Nations Children's Fund), wasting rates of 10% or more require urgent action. Other countries that have similar rates include Niger and the Central African Republic.

Although there are many factors involved in the poor rates of growth of Indigenous children, the most important appear to be living in overcrowded, unhygienic conditions, with repeated infections and poor nutrition. This highlights the fact that improved growth and getting rid of malnutrition in Indigenous communities requires these changes:

Overweight and obesity

When the amount of food eaten by a person (measured as energy in kilojoules) is greater than the amount of energy being used (through daily activity and exercise) the extra energy is stored as fat and the person puts on weight. Excess body fat leads to being overweight (a bit too much fat) or being obese (too much fat). A person's BMI (see above for calculating BMI) will tell you whether he/she is overweight or obese, normal weight or underweight.

Obesity is often caused by eating too many refined carbohydrates (foods made from white flour or containing lots of sugar), drinking too much alcohol, and not getting enough exercise. It can lead to high insulin, cholesterol, lipid and blood pressure which are all risk factors for heart disease.

The main diseases that affect the health of Indigenous people are diseases caused by obesity:

A recent survey by the National Aboriginal and Torres Strait Islander Health Service (NATSIHS) in 2004-05 found that obesity is an increasing problem in the Australian Indigenous population. Over a quarter (28%) of Indigenous people aged 15 years or older were overweight and over a quarter (29%) were obese. This adds up to more than half the population (57%) being either overweight or obese.

In the non-Indigenous population more than half the population (52%) was also found to be overweight or obese. The main difference between the two populations was the greater proportion of obese Indigenous people (29%) than non-Indigenous people (17%). This difference was especially true for females.

Graph for BMI of Indigenous and non-Indigenous males

Graph 1 Comparison of Indigenous and non-Indigenous males in each of the BMI categories (shown as proportions of the population in percentages)

Comparison of Indigenous and non-Indigenous females in each of the BMI categories (shown as proportions of the population in percentages)

Graph 2 Comparison of Indigenous and non-Indigenous females in each of the BMI categories (shown as proportions of the population in percentages)

Comparison of Indigenous and non-Indigenous people of both sexes in each of the BMI categories (shown as proportions of the population in percentages)

Graph 3 Comparison of Indigenous and non-Indigenous people of both sexes in each of the BMI categories (shown as proportions of the population in percentages)

Non-nutritional factors that can affect nutrition and growth

Introduction

The food we choose eat is partly affected by what foods are available to us.

The main factors that determine what food is available to us (to be discussed in detail below) are:

The diets of many Indigenous people are high in energy, fat, refined carbohydrates and salt, and low in fibre and certain essential nutrients (such as folate, retinol and other vitamins). This is because healthy foods are not readily available.

Socioeconomic factors

Indigenous Australians are generally less well off than other Australians when we compare socioeconomic factors such as:

Education

The Census (a survey that measures all the socioeconomic factors of people all over Australia) in 2006 showed the following education results:

Comparison in percentages of education levels of Indigenous and non-Indigenous people aged 15 years or older

Graph 4 Comparison in percentages of education levels of Indigenous and non-Indigenous people aged 15 years or older

Employment

The 2006 Census compares the employment status of Indigenous and non-Indigenous Australians.

Comparison of employment status in percentages between Indigenous and non-Indigenous Australians

Graph 5 Comparison of employment status in percentages between Indigenous and non-Indigenous Australians

Income

The 2006 Census showed:

Environmental factors

The environmental factors that play a part in our nutrition and growth are the physical environment in which we live:

The living conditions for many Indigenous people, especially those living in remote areas, are not very good. Their homes are overcrowded, they do not have safe, clean drinking water, the plumbing is not safe, there is little room to store food, and no proper equipment to cook it on.

Housing

The 2006 Census showed:

Water and electricity

A discrete Indigenous community is a community with physical or legal boundaries, and one which is to be used by mostly Aboriginal or Torres Strait Islander people. A survey was done in 2006 in 1187 discrete communities showed:

Cooking and storage

The freshness of the food and its variety are affected by the need for food to be stored suitably and protected from contamination. This means that if there is no refrigeration fresh meat and milk will not be available, only canned meats and long-life milk. Likewise if mice or weevils are a problem, foods must be in sealed containers.

There has not been any information collected on cooking arrangements and food storage conditions in Indigenous communities, but these are thought to be ‘inadequate, and sometimes dangerous' for many Indigenous people living in remote areas.

Geographic factors

Where we live makes a big difference to what foods are available to eat.

Many Indigenous people live in rural or remote areas where fresh, nutritious food is not always available, and the community store is the only place to shop. In many cases the store gets new supplies only once a week, or, as in some areas of the Torres Strait, even less often than that.

After long journeys in trucks, the food arrives in poor condition and some has to be thrown away. Transport is expensive so the food costs a lot.

Those foods that don't need much or any preparation (and are less nutritious) are often preferred because they are convenient. The fruit and vegetables are less popular because they have been bruised and damaged during the trip, and also need more preparation.

In 2006 a survey was done in Queensland - the 2006 Healthy Food Access Basket Survey. It showed that food costs were a lot higher in rural and remote communities than in metropolitan and regional centres:

A similar survey in the Northern Territory found that prices at remote stores were higher than in supermarkets and corner stores in Darwin.

Comparison of food prices between Darwin stores and remote communities

Graph 6 Comparison of food prices between Darwin stores and remote communities

Community stores have a big influence on the diets of the people living in the community. For example, in some communities the stores support healthy nutrition programs. By providing a wider variety of healthy foods and healthy ideas in their stores, the store owners also benefit by selling more of these products.

Store managers have a big influence on what foods are available in remote Indigenous communities and so play a big part in improving the nutrition of the customers. A project at Minjilang (Croker Island, Northern Territory) showed that improvements of this kind only work when the community members are involved. A study in New South Wales found that the main factors that made a difference to what the community members bought were:

Some other factors that affect remote community stores are:

National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP)

The National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000-2010 was developed as part of the nutrition strategy for all Australians called Eat Well Australia: a national framework for action in public health nutrition, 2000-2010. Both strategies were endorsed (put into action) by the Australian Health Ministers' Conference in August 2001.

The federal government recognised that poor diet is a major reason why many Indigenous people have poor health and why so many Indigenous people suffer from chronic diseases.

The NATSINSAP identified seven important areas to be improved:

They also paid for a NATSINSAP Project Officer to do this work.

Summary

Throughout their lives, many Indigenous people suffer from major health problems because of poor nutrition. At birth Indigenous babies are generally much lighter than non-Indigenous babies.

After birth most Indigenous babies grow well until they can no longer survive on breast milk alone. At this time they need some solid food as well. Sometimes what they are given is not enough or not healthy, or perhaps is contaminated if they live in areas where there is inadequate housing, no sewerage, or no fresh water. At this time the children are at risk of catching infections. This can develop into a vicious cycle: the children are undernourished so their bodies cannot fight the infections, so they get sick, and when they are sick they are at risk of getting more infections because the food they eat is not making them strong enough to fight the infections. All this can prevent them from growing as big and strong as they could have been. This in turn can mean that mothers are not as strong and healthy as they could be, and this will have a bad effect on their babies.

From the time they become young adults, many Indigenous people start to gain a lot of weight, eventually becoming overweight or obese. Being overweight or obese is linked to many chronic diseases, especially cardiovascular disease and diabetes.

The main reason for these problems of growth and nutrition is the social disadvantage many Indigenous people experience, namely low levels of education, high levels of unemployment, low incomes and an unsatisfactory environment.

Two of the targets for ‘closing the gap' between the health of Indigenous and non-Indigenous Australians - to increase Indigenous life expectancy and to reduce child and infant mortality - are related to nutrition and diet. However, improvements in nutrition will need to be accompanied by improvements in social disadvantage (mentioned above). For this reason NATSINSAP remains as important today as it did in 2001.

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