Exploring Nutritious food as a Key Tool in Closing the Gap in Indigenous Health Inequality

By Lydia O'Meara

Lydia attended the 2015 OECD Forum in Paris. 

Abstract

  • Recommendation 1 – Focus initial public nutrition policy and programme implementation on improving nutritional biochemical markers in the first 1000-days of Indigenous childhood life in remote areas of Australia.
  • Recommendation 2 – Commit to re-orienting healthcare from a tertiary model of healthcare to a preventive model as per the Australian government’s responsibility under the Ottawa Charter of Health.
  • Recommendation 3 – Urgently address the Indigenous nutrition policy vacuum in Australia.
  • Recommendation 4 – Ensure sustained bi-partisan political support to facilitate consistent collaborative action with a united long-term commitment to implementation and evaluation funding for food and nutrition policies and programmes.

Introduction

Health inequalities in underprivileged populations have been identified by the OECD as a global issue that affects rich and poor countries alike.[1] Many OECD countries enjoy a high life expectancy yet, it is well known that health disparities exist amongst different socioeconomic groups within relatively healthy populations such as Australia.[2][3] People with poor physical or mental health are less likely to be employed.[4] In contrast, healthy populations enjoy life more, are more likely to achieve a greater education attainment and therefore contribute to tax revenue as active participants of a country’s workforce.[5][6] Thus, it is imperative that governments not only acknowledge national health inequality issues but support this recognition with a long-term commitment to implementing practical policy and programmes to improve the health outcomes of disadvantaged populations.

This paper outlines the urgent need to improve the nutritional status of Australian Indigenous children during the first 1000 days of life (including in utero) to prevent nutrition-related conditions whilst providing the best opportunity for cognitive and physical development in the remote Australian setting. It includes a broad discussion on the current preventive health and nutrition policy and programme within Australia with recommendations for government to first demonstrate practical action to re-orient the Australian healthcare model to prioritise preventive healthcare.  Further followed by a discussion on the need for targeted nutrition policy and programme implementation and evaluation funding to best support the human right for equal opportunities to health as they relate to the Indigenous population in remote areas of Australia. It concludes that there is an urgent need for bi-partisan political support with direct leadership from the national level to ensure a consistent and sustained approach across all levels of government to provide action crucial to the success of long-term, young age-group nutrition interventions required to prevent chronic diseases across the lifecycle.

This paper acknowledges and develops synergies, where relevant, with the Australian National Aboriginal and Torres Strait Islander (ATSI) Health Plan 2013-2023;[7] This paper also takes into account the OECD’s recommendations to member states to establish a national healthcare productivity agenda and the need for innovative, cost-effective initiatives to ensure a sustainable health care system for future generations.[8]

First 1000-days of Indigenous childhood life in remote areas

Ensuring adequate nutrition in pregnancy and during the first 1000-days of a child’s life is crucial for supporting childhood development and school attainment.[9][10] Further to this, nutrition and growth in children is a major determinant of health across the lifecycle, including the prevention of chronic diseases such as Type 2 Diabetes, cardiovascular disease and chronic kidney disease; chronic conditions which affect Indigenous populations in Australia.[11] [12]  According to the World Health Organisation (WHO), 162 million young children suffer under-nutrition and this contributes to approximately half of the global deaths of under-5 year olds.[13] In the latest United Nations (UN) Millennium Development Goals Report 2014, the WHO has called for member states to create bolder initiatives and focus efforts where significant health disparities exist as part of each state’s commitment to the universal post-2015 development agenda.[14]

Australian researchers have frequently identified the urgent need to address nutrition deficiencies for Indigenous children within Australia. For example, in the Northern Territory, the Growth Assessment and Action 2009 Report revealed that 33% of children aged under-5 years old, living in rural and remote areas of Australia, were either underweight, ‘wasted’ or ‘stunted’, with one third of these cases (11%) being attributed to ‘wasting’.[15]  Stunting is defined as low height for age and it reflects the cumulative effects of childhood under-nutrition during the critical 1000-day window covering pregnancy and the first 2-years of a child’s life.[16] In contrast, wasting is defined as a low weight for height. Stunting contributes to poor cognitive function and impaired education attainment whilst wasting is a strong predictor of childhood mortality in under-5-year olds.[17] Of note, the United Nations Children’s Fund (UNICEF) advises that wasting rates of 10% or more require urgent action. To put this in perspective, 11% of Australian Indigenous children in the Northern Territory are wasted, a rate comparable to those experienced in the Central African Republic, signifying an urgent humanitarian need. [18][19]

Adequate antenatal nutrition is crucial for preventing stunting and wasting in early childhood. The Australian Early Childhood Nutrition and Anaemia Prevention Project overseen by The Fred Hollows Foundation highlighted the need to implement preventive nutrition measures on Indigenous children before 6-months old.[20] In remote northern Indigenous communities of Australia, 56% of 6-month olds were found to be anaemic.[21] The key preventive age for increasing iron intake to prevent anaemia is 6 months, thus Indigenous infants are at increased risk of nutritional deficiencies due to inadequate in-utero nutrition.[22] To use a case study from abroad, outcomes from India’s first applied nutritional programme, the Integrated Child Development Service scheme, can act as a warning for Australia to ensure the focus of nutrition interventions is on the age group with optimum impact on long-term health benefits. Indian researchers identified that the 30-year, national child nutrition programmes needed to re-orient their focus on improving the nutrition status of children during the vulnerable first 2-years of life in contrast to what had previously been an emphasis on supplementary nutrition and preschool education for Indian children aged 3-6 years.[23] Full-scale change will take decades to achieve due to trans-generational effects. Therefore, the Australian government should provide international leadership by focusing Indigenous nutrition policy and programme implementation on improving nutrition in the first 1000-days of Indigenous childhood life, including adequate nutrition in utero, which would contribute to the UN’s Sustainable Millennium Goal’s post-2015 development agenda.

The geographical remoteness of many Indigenous communities affects their health. In remote areas, it is well known that there is a poor supply of healthy foods and that the healthy food that is available, is known to be substantially more expensive, which in turn influences food purchasing choices.[24][25] In Queensland, 51.3% of ATSI peoples reside in Cape York, an area in the far north of the state which is classified as very remote.[26] The ATSI populations in Cape York die approximately 20-years earlier than their non-Indigenous compatriots, which is double the average national Indigenous life expectancy gap. [27] [28] Thus, it is crucial the focus of nutrition interventions for Indigenous populations should also take into account the multi-compounding effects remoteness has on food supply, food security and subsequently health.

Innovative health initiatives have been developed and implemented by the private aboriginal health sector. ‘We need to start with healthy mums in pregnancy and during breastfeeding’ states one Indigenous Health Worker.[29] Two of these initiatives targeting the first 1000-days of a child’s life have been identified as appropriate to be broadly distributed across remote Indigenous communities.[30] For example, Apunipima in the Cape York area of Australia, deliver the award-winning Baby One programme. Through the use of a ‘baby box’, the Baby One programme utilises incentives to engage parents and children with local Indigenous health workers.[31] This programme empowers and educates Indigenous health workers to provide culturally acceptable health promotion messages to Indigenous women. The baby box provides practical baby care items such as a safe baby sleeper, nappies, and a fruit and vegetable voucher; items that provide a conversation starter for the Indigenous health worker to provide health promotion messages to pregnant and lactating mothers, including nutrition advice. The Baby One programme has won awards for excellence in collaborative healthcare, team innovation and implementation.[32] It embodies a successful, culturally competent, geographically intuitive, community-oriented preventive programme focused on the target audience that has the most potential to create lasting lifecycle and intergenerational health improvements. Thus, such initiatives as the Baby One programme provide an opportunity for government to support a broader roll-out and adaption of proven nutrition policy and programme to best improve the nutritional biochemical markers of Indigenous children in the first 1000 days of life in remote areas.

Ottawa Charter of Health: re-orienting healthcare from a tertiary model of healthcare to a preventive model

Prevention is often more cost-effective than cure and the majority of chronic diseases are preventable or onset-delayed by a healthy lifestyle, including a nutritious diet and adequate exercise.[33] The OECD identifies social justice as an important motivation for implementing reasonable action to overcome avoidable systemic differences in health.[34] In 1986, the Ottawa Charter of Health originated in Canada as a list of identified action areas that industrial countries can implement to best achieve the objectives of the WHO’s Health for All by the year 2000 initiative to reduce health inequalities.[35] The Ottawa Charter of Health upholds the principles of social justice as crucial to the effective implementation of health promotion with the objective that all members of a community are entitled to equal opportunities to health. More specifically, signatories to the charter, including Australia, committed to actions such as advocating a clear political commitment to health equity in all sectors, actions to tackle the health gap within and between societies, and an overall re-orientation of health services towards utilising resources for health promotion purposes. [36] 

A focus on reducing health disparities is significant to Australia. For example, the ACCHS service report outlines that 43% of identified service gaps in Indigenous primary health care relate to preventive health and the early detection of chronic disease.[37] For example, Indigenous adults are three times more likely than non-Indigenous Australians to have diabetes.[38] This is a conservative figure as it is estimated that more than one out of every ten Indigenous adults do not know they have diabetes.[39] Further to this, 53.1% who do have diabetes also have a co-morbidity of chronic kidney disease.[40] Indigenous adults living in remote areas are twice as likely to have chronic kidney disease compared with those in urban areas; the cost of delivering renal support to remote areas is also substantially more expensive.[41] Thus, practical preventive healthcare initiatives are essential to implementing the principles of the Ottawa Charter of Health that support the human right of remote Indigenous populations to fair and equitable health opportunities.

In 2008, all major political parties in Australian committed to implementing actions to close the gap in health disparities between ATSI and non-Indigenous Australians within a generation.[42] Despite this being a national policy priority, no significant change in life expectancy in the Indigenous population has been recorded since the 2006 baseline up until 2013.[43]In fact, 81% of ATSI death rates continue to be directly attributed to chronic diseases such as Type 2 Diabetes and chronic kidney disease, followed closely by death from all types of cancers.[44] The Australian government has committed to developing practical reforms as part of an Implementation Plan for the National ATSI Health Plan 2013-2023 with the intent of accelerating progress for the Close the Gap targets. Accelerated progress is required to close the gap in life expectancy by the target deadline of 2030.[45] Despite these commitments, the most recent Queensland and Commonwealth 2014 budgets have abolished much of the preventive health funding in what can only be seen as an attempt at ‘cost saving’.[46]

In 2012, the Queensland state government abolished the regional public health nutrition services in Queensland, with a cut of approximately 150 public health nutrition and health promotion jobs.[47] The abolishment of these services prevented the Cairn’s Public Health Unit Nutrition Team from supporting the implementation of the Cape York Food and Nutrition Strategy which subsequently impairs the collaboration and momentum  needed to develop and roll-out a comprehensive action plan.[48] In the May 2014-2015 budget, the federal government cut almost $368 million by abolishing the National Partnership Agreement on Preventive Health.[49] The loss of this partnership will mean cuts to public health programmes that deal with preventing obesity, cancer, and diabetes, including those in remote and rural areas.

Further, the current LNP government abolished the Australian National Preventive Health Agency by removing $6.4 million of funding.[50] More specifically for Indigenous communities, the National Partnership Agreement on Indigenous Early Childhood Development ceased in mid-2014.[51] From 1 July 2015, the government is transferring funding from Medicare Locals to the Primary Health Networks.[52] Most Medicare Locals have proactively planned and implemented initiatives in the areas of Aboriginal health and e-health for rural and remote areas whilst also addressing some social determinants of health and community capacity-building strategies. In contrast, the Primary Health Networks is a much larger, clinically focused network, thus initiatives in locally appropriate chronic disease prevention may be lost. Therefore, if government would like to accelerate progress to close the gap in Indigenous life expectancy, it is crucial that they should first re-commit to re-orienting healthcare from a tertiary model of healthcare to a preventive model as per their responsibility under the Ottawa Charter of Health, followed by funding practical actions to prevent nutrition and lifestyle-related chronic diseases in rural and remote Indigenous communities as part of their commitment to the Implementation Plan for the National ATSI Health Plan 2013-2023.

Preventive healthcare is also an economically sustainable model of healthcare. Prevention accounts for approximately only 3–4% of total health expenditure in OECD countries; however, such measures can considerably reduce the human and financial burden of disease in the long-term.[53] Healthy individuals enjoy life more, have more opportunities to perform better at school and therefore contribute to tax revenue as active participants of a country’s workforce.[54] For example, an increased Indigenous workforce participation would lead to a 1.15% larger Australian economy with an economic gain of approximately $24 billion (estimated on 2012/13), $7.2 billion increase in tax revenues, and national gains of $6.5 billion in remote areas.[55] In conjunction to the increase in tax revenue,  the Australian Government would save $4.7 billion in reduced expenditure in health and social security outlays.[56] Efficient use of healthcare budgets results in improved health outcomes, reduces inter-generational unemployment and incidentally leads to a greater economic dividend in the form of increase taxation revenue whilst also lessening welfare expenditure spent on addressing social and health issues post-diagnosis of disease. Thus, the Australian government cannot afford not to invest in preventive health care, especially as it relates to health inequalities in Indigenous populations in remote areas.

The Indigenous Nutrition Policy Vacuum in Australia           

A review of Australian Aboriginal health policies and strategies has exposed a nutrition policy vacuum.[57] Indigenous dietary risk factors contribute more towards the disease burden within Australia than either alcohol or tobacco. [58] More specifically, 28% of the Indigenous health gap stems from the negative impact of nutritional related conditions signifying how essential nutrition is for increasing ATSI health and wellbeing.[59] [60] In comparison, 17% of the health gap is acknowledged to be caused by tobacco. [61] The 28% of nutrition related conditions that contribute to the Indigenous health gap are made up by 16% obesity, 7% high cholesterol, and 5% low fruit and vegetable intake.[62]

A study undertaken in the top-end of Australia that included  Western Australia, the Northern Territory and Queensland discovered that 67% of food intake for indigenous infants and children did not meet Australian Dietary Guidelines.[63] Of note, it was reported that 95% and 55% of 6-9-month old children ate low amounts of fruit and iron-rich foods respectively, levels that are inadequate to meet iron demands necessary for a 6-month-old child.[64] This study identified a priority need to determine the prevalence and relative spread of early-onset anaemia in remote northern Australian communities with a goal to implement urgent action.[65] The current preventive health objective of the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes outlines the need to support drug and mental health services to reduce chronic disease risk factors such as smoking and alcohol and drug abuse, however, nutrition is not specified as a risk factor requiring immediate action. [66]

Given that nutrition is a determinant of chronic disease, child development and school attainment and contributes to wellbeing in in such areas as maternal health and birth weight,[67] [68] both the  National Aboriginal Health Strategy 1989 (NAHS) and the  Health is Life 1997 inquiry identified nutrition as the key tool to improving the persistently poor health of Indigenous Australians.[69] Both policies specified recommendations to improve nutrition status and address food security issues in remote communities.[70] Of note, the NAHS evaluation highlighted a lack of project funding and effective strategy for implementation to adequately affect Aboriginal health.[71] A 10-year national agenda, The National ATSI Nutrition Strategy and Action Plan 2000-2010 (NATSINSAP) emphasised an urgent need to improve the nutrition intake of ATSI populations to prevent chronic diseases that contribute to a reduced life expectancy. Worryingly, this sole national agenda of indigenous nutrition has not been continued beyond 2010 and the post-evaluation has not been made public for unknown reasons.[72]

Further review has revealed that funding for many Indigenous nutrition and food security related policies and strategies have expired with no specific continuation of nutrition interventions in implementation. Of concern, important omissions have been noted, such as nutrition no longer being specified as a strategy of primary health care, holistic health promotion, management of low birth weight, and childhood development.[73] Ironically, this lack of practical nutrition strategies appears despite nutrition being named as an immediate priority area.[74] Thus, it is imperative that nutrition preventive interventions aimed at early life be included as a key goal of the Close the Gap implementation initiatives.

It is acknowledge that the National ATSI Health Plan 2013-2023 includes an objective to improve access to nutritious food via the Australian National Food Policy (ANFP) with a focus on at-risk mothers, infants and children.[75] However, the ANFP is currently under review and it is to be seen whether this policy will address the urgent nutrition needs of indigenous children during the first 1000 days of life.[76] The National ATSI Health Plan also has an objective to review and improve the application of the Indigenous Chronic Disease Package over the next decade.[77] It is noted that the overarching description of this package pertains to delivering care after a chronic disease has been diagnosed in contrast to preventing the development of the condition in the first instance.

On a positive note, the Commonwealth government has continued funding for both the Indigenous teenage sexual and reproductive health, plus the young parent support initiative for health promotion and antenatal care for young mothers. Nonetheless, this continued funding for young parent support is only for one year and OECD research reveals that age group interventions take decades to come to fruition.[78][79] In conclusion, it is crucial that government urgently address the vacuum of Indigenous nutrition policy in Australia, especially as it relates to sustained implementation and evaluation funding beyond the mere initial development costs with increased funding for policy and programme targeted at antenatal and early childhood nutrition.

Need for Sustained Bi-Partisan Political Leadership to Facilitate Collaborative Long-Term Action

A long-term, consistent approach needs to be adopted by all levels of government to allow the effects of young age-group interventions to come to fruition. For example, work by the OECD notes that interventions targeting children yield significant results only after approximately 40-years.[80] [81] Since the 1970s, developed countries such as the United States, Canada, and the United Kingdom have implemented programmes to address food security in underprivileged populations and remote areas. One review of food subsidy programmes in high-income countries aimed at pregnant women and children concluded that such programmes can result in a 10-20% increase in key nutrients (1-2 serves of fruit and vegetables a day), an increase that has the potential to reduce the rate of chronic disease if sustained over the long-term.[82] More specifically, for each serving of fruit and vegetable intake, it is estimated that an individual will experience a 4% decrease in the risk of coronary heart disease.[83]

In contrast, if a short-term budget mindset dominates the political environment, it can hamper cost-effective, long-term initiatives especially if piecemeal, sporadic funding hampers adequate programme development, implementation and evaluation.[84] Research in Europe demonstrates that funded programmes are not adequately evaluated, highlighting an urgent need to include integral evaluation as a component of all future nutrition policy and initiatives to best provide a sound evidence base from which future reliable and cost-effective policies might be formed.[85] Evaluations on short-term projects also have their shortfalls with intermediate outcomes, such as changes in attitudes or purchasing behaviour, not adequate indicators of health benefits as demonstrated by studies of behavioural failure.[86] Therefore, sustained eating behaviour needs to be supported long-term with adequate evaluation and customisation to produce meaningful outcomes.

Both the swing between political parties and the international financial environment can adversely affect the success of healthcare. Internationally, the 2009 Global Financial Crisis (GFC) has affected healthcare expenditure, especially as governmental spending relates to health policy and programmes.[87] Since the GFC, the OECD has noted a reduction in preventive healthcare expenditure in some OECD countries that raises concern for the continued health and wellbeing of the most vulnerable groups within these countries, highlighting the challenge of balancing efficient healthcare with health equity.[88] Despite multiple countries committing to the Ottawa Charter of Health’s re-orientation to a preventive model of health care in the 1980s, there is limited evidence of implementation in the last 20 years.[89] It is acknowledged that it is not simple to achieve healthcare reforms in a well-ingrained tertiary model of clinical care.[90] Barriers to reform could be in part due to the interplay between social outcry for investment in the traditional tertiary model of healthcare, medical professional sway and the political preference for a ‘quick fix’.

For example, the OECD emphasises that addressing microeconomic efficiencies as they relate to health equality is the most difficult area to achieve improvements, due in part to the sway of medical professions to block reforms, which may be motivated by a perceived threat to economic interests or professional freedoms.[91] Governments are in a unique position to champion a shared national vision for preventive health care along with provision of overarching leadership supporting state and local governments with essential resources needed to implement policy into action.[92] It is acknowledged that instigating and maintaining healthcare reform is not always easy, nevertheless, to achieve a national healthcare productivity agenda it is essential that opposing government party’s work together to support innovative change for both improved social justice and economic outcomes for disadvantaged groups.[93] Thus, it is imperative that interventions targeted at children are implemented in a comprehensive manner, sustained long-term and regularly evaluated and adapted to the ever changing needs of each unique community group to best utilise nutrition to prevent chronic disease.

Conclusion

In conclusion, health and nutrition is important for national development, especially in the context of Indigenous populations. Preventive nutrition policy and programmes are cost-effective and sustainable into the future, aligning with OECD and WHO recommendations for improving health inequalities in disadvantaged populations. These preventive interventions need to focus heavily on the crucial first 1000-days of a child’s life through continuation and broader implementation of such innovative initiatives as Apunipima’s Baby One programme.

A long-term, consistent bi-partisan political approach with adequately sustained funding for implementation and evaluation should be adopted by all levels of government to allow the effects of young age-group interventions to come to fruition. It makes good sense to invest public health expenditure into preventing childhood nutrition deficiencies that will improve childhood cognitive and physical development, broaden a child’s opportunities to educational attainment, lead to improved employment prospects and empower individuals with the tools to break the chronic poverty cycle. It is crucial that government focus on childhood nutrition as it relates to improving Indigenous child health and wellbeing with the intent of preventing chronic diseases to reduce the Indigenous life expectancy gap.

Full Footnotes and Bibliography can be found here or by copying the following URL into your browser: http://bit.ly/LydiaOMeara