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3 July 2012, 6.43am EST

Innovative strategies needed to address Indigenous obesity

OBESE NATION: It’s time to admit it – Australia is becoming an obese nation. This series looks at how this has happened and more importantly, what we can do to stop the obesity epidemic. Today Julie Brimblecombe discusses the incidence of obesity in Indigenous communities. After tobacco, overweight…

H5dm5dp5-1341202489 — Just beyond the built community lies a health-promoting environment providing cultural, spiritual and physical nourishment. misha.penkov/Flickr

OBESE NATION: It’s time to admit it – Australia is becoming an obese nation. This series looks at how this has happened and more importantly, what we can do to stop the obesity epidemic.

Today Julie Brimblecombe discusses the incidence of obesity in Indigenous communities.

After tobacco, overweight and obesity contributes most heavily to the disease burden affecting Aboriginal and Torres Strait Islander Australians. It accounts for 16% of the health gap between Indigenous and non-Indigenous Australians, and is linked with physical inactivity, which accounts for a further 12% of the gap.

Type 2 diabetes, cardiovascular disease and kidney failure – each driven by obesity – are all rife among this population. Promising inroads have been made into tobacco cessation through political commitment, legislation, and community support. But obesity prevention in remote Indigenous Australia has not received equal attention.

For the individual most often affected by diseases associated with overweight and obesity during what should be the most productive years of his or her life, the social, health and economic costs of obesity are enormous. And this effect ripples through society.

Paradoxically, the poor are most affected, and many remote Indigenous households are now dealing with the double burden of obesity in adult members and under-nutrition in children.

Traditionally, Indigenous Australians were physically lean and did not gain weight with age. Thirty years ago, a small family group of Aboriginal people living “a traditionally oriented lifestyle” in north-east Arnhem Land were extremely slim (BMI of 16.7). And showed no risk of type 2 diabetes or heart disease.

Fast forward 20 years and this picture had completely changed. Half of the population in a north-east Arnhem Land community aged 15 years and over (47.3%) were still considered lean (BMI of less than 22), and this was particularly the case for young people (15 to 24 years), all of whom showed no sign of type 2 diabetes. In those of middle-age (35 to 64 years), however, 38% of the study population were overweight or obese.

Many factors contribute to people becoming overweight or obese in remote Indigenous communities. Most such communities are obesogenic environments because food prices (in the NT) are 45% more than urban centres; few healthy fast food options exist; there are limited recreational facilities and safe walking paths; and there’s inadequate housing. What’s more, there are often poor cooking and storage facilities and limited opportunities to access meaningful information on healthy food.

It’s now recognised that these factors are largely driven or controlled by elements that are external to the individual. At a national level, strategies are increasingly focusing less on the individual and ideas of a lack of self-control, and more on better understanding and modifying the obesity-promoting environment.

The environment is complex, and like strategies for tobacco cessation, lowering obesity levels requires a coherent, multi-level, multi-sector integrated approach – supported by political will and resources. But the environment of remote Indigenous communities is also unique in a number of ways – and this may make it more conducive to effective action.

When Indigenous Australians lived a traditional lifestyle, their diets were rich in lean animal foods that provided abundant protein, and sources of slowly digested carbohydrate. Marguerite Carstairs

First, remote communities have the benefit of a food system that can be more clearly demarcated and defined than the urban setting. Second, in general, community leaders are highly committed to health improvement and support an integrated and holistic approach that resonates with an Aboriginal view of health. This can promote excellent coherence within a community, encouraging different sectors to work together.

In many settings, just beyond the built community lies a health-promoting environment that provides cultural, spiritual and physical nourishment for many community residents. The remote community Gunbalanya in Arnhem Land, for instance, overlooks a wetlands billabong teeming with long-necked turtle, file snack and fresh water fish.

Just down the track from the Nyirripi community in Central Australia, bush tomatoes and sultanas line the unsealed road and honey-ants are plentiful. Community elders are desperate to maintain these environments and their spiritual, cultural and physical connection to the land. They are also eager to educate and connect the younger generations to this environment.

When Indigenous Australians lived a traditional hunter-gatherer lifestyle, their diets were rich in lean animal foods that provided abundant protein, and sources of slowly digested carbohydrate. Energy dense foods were highly-prized and limited by season and their procurement burned calories.

Now, food stores in remote communities stock mainly energy-dense, nutrient-poor processed foods that are high in fat, sugar and salt. These processed foods provide excessive calories at a relatively low price, compared with the high expense of fresh nutrient-rich foods (fruit, vegetables, lean meats, fish, dairy and whole-grain cereals). So cheap refined carbohydrates and processed foods now make up the bulk of the diet available to most people living in remote Indigenous communities.

There’s no question that the price of food influences consumption patterns. So economic levers are a logical approach to help move the dietary balance closer to the traditional diet and improve health outcomes – and many Aboriginal people in communities support this.

Tax policies, although getting traction in the United States, United Kingdom and Denmark, need closer consideration in Australia, as remote Indigenous families may be the hardest hit. They already spend a greater part of their budget on food. Subsidies are likely to be more effective.

Rigorous testing of solutions is needed to inform fiscal policy to curb overweight and obesity in remote Indigenous Australia.

Aboriginal people living in remote communities are among Australia’s poorest. Yet they pay much more for food, and have limited availability to a healthy diet. Innovative economic strategies are needed to help alter this imbalance.

This is part ten of our series Obese Nation. To read the other instalments, follow the links below:

Part one: Mapping Australia’s collective weight gain

Part two: Explainer: overweight, obese, BMI – what does it all mean?

Part three: Explainer: how does excess weight cause disease?

Part four: Recipe for disaster: creating a food supply to suit the appetite

Part five: What’s economic growth got to do with expanding waistlines?

Part six: Preventing weight gain: the dilemma of effective regulation

Part seven: Filling the regulatory gap in chronic disease prevention

Part eight: Why a fat tax is not enough to tackle the obesity problem

Part nine: Education, wealth and the place you live can affect your weight

Part eleven: Two books, one big issue: Why Calories Count and Weighing In

Part twelve: Putting health at the heart of sustainability policy

Part thirteen: Want to stop the obesity epidemic? Let’s get moving

Part fourteen: Fat of the land: how urban design can help curb obesity

Part fifteen: Industry-sponsored self-regulation: it’s just not cricket

Part sixteen: Regulation and legislation as tools in the battle against obesity

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9 Comments sorted by

Mark Carter

logged in via Facebook

"limited recreational facilities and safe walking paths;" -are you serious? These communities are usually in the middle of the most heartbreakingly beautiful country, walking paradise. And how many 'safe walking paths' do you think there were 40 years back?
Its ironic that the photo on this article is of Mt.Sonder and the Finke River- a national park surrounded by indigenous communities which is very rarely actually visited by aboriginal folk unless shepherded there by a public employee as part of some program or other.
My experience of aboriginal people in the NT at least is that many see physical exercise as a chore to be avoided whenever possible- not particularly different from the rest of Australia really...

12 months ago report
rory robertson

rory robertson is a Friend of The Conversation.

former fattie

Thanks for your piece Julie, and congratulations on the work of the Menzies School in this critical area. Actually, I'm just back Sydney after most of a week in Cape York, driving back to Cairns via one of the Cape's many remote Aboriginal communities. Notably, thumb-tacked onto the noticeboard outside the (one) community grocery store was a report from the Menzies School noting that sugary products - particularly softdrinks (95% of them full-strength not diet) - are a huge part of dollars spent…
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Thanks for your piece Julie, and congratulations on the work of the Menzies School in this critical area. Actually, I'm just back Sydney after most of a week in Cape York, driving back to Cairns via one of the Cape's many remote Aboriginal communities. Notably, thumb-tacked onto the noticeboard outside the (one) community grocery store was a report from the Menzies School noting that sugary products - particularly softdrinks (95% of them full-strength not diet) - are a huge part of dollars spent at the store in recent months.

It is clear to many involved in public health that sugary foods and drinks are a key driver of Aboriginal and other Australians' growing problems with obesity, diabetes and other chronic diet-related diseases (http://www.nt.gov.au/health/healthdev/health_promotion/bushbook/volume2/chap3/food.html ).

Accordingly, minimising added sugar in our food supply is an obvious low-hanging fruit in the battle against obesity, diabetes and other "diseases of affluence". Unfortunately, the idea that sucking down heaps of unnecessary sugar is really bad for you and your kids is not widely understood in many parts of Australia. Better education - and more heeding of available nutrition advice - hopefully will tend to change that over time, improving today's woeful (if unsurprising) health outcomes.

What is extremely unhelpful in the process of improving health outcomes are false and misleading reports by nutritionists claiming that the consumption of added sugar is unrelated to rising rates of obesity and diabetes. In particular, recent work of high-profile low-GI advocates from the University of Sydney - Professor Jennie Brand-Miller and Dr Alan Barclay - has featured a series of (uncorrected) spectacular false claims seeking to exonerate sugar. They claim:

• Australian sugar consumption has undergone a "substantial decline" over "the past 30 years", so sugar and obesity are unrelated. (This is the high-profile but actually non-existent “Australian Paradox”);
• Cars not humans consumed any uptrend in "available" sugar over that period. (Yet ethanol production in Australia does NOT use raw sugar as feedstock!);
• Australians' fructose intake today probably is little different from levels enjoyed in pre-European times. (So commercial sugar-cane production and sugary food imports changed nothing?); and
• "There is an absolute consensus that sugar in food does not cause diabetes." (Yet raucous debate rages all around?)

Each of these claims is false. The facts on these matters are documented at http://www.australianparadox.com/ , especially at #10 and #11 on the LHS. Also see http://www.smh.com.au/national/health/research-causes-stir-over-sugars-role-in-obesity-20120330-1w3e5.html and http://www.smh.com.au/business/economist-v-nutritionists-big-sugar-and-lowgi-brigade-lose-20120307-1uj6u.html .

The University of Sydney crew's repeated claim that "There is an absolute consensus that sugar in food does not cause diabetes" is particularly ridiculous, given an ongoing debate that already has lasted centuries. This debate to an extent remains about whether anything ELSE but excessive sugar intake is involved.

After all, "the sugar sickness" - as diabetes reportedly has been known on and off for generations - apparently kept turning up - as the British Empire expanded across the globe - soon after sugar was introduced and became popular in distinct local populations. For those interested in actual facts, this telling history is documented by Gary Taubes in Chapter 6 of his fascinating book "Good Calories, Bad Calories".

The University of Sydney team's extraordinary clumsiness with key facts on its own chosen "special subject" of sugar introduces the issue of the low-GI industry’s serious but undisclosed conflict of interest. The low-GI crew's fundamental problem is that fructose - the “sweet poison” half of table sugar (the other half is glucose) - has a super-low GI of 19, towards the very bottom of the GI scale.

Fructose is super-low GI so it must be a “good" food, right? And if any processed food product is not low GI, then just add fructose because adding fructose is the recipe for a lower GI reading. Food companies keen to get on board the Low-GI train have an incentive to add fructose, to make processed food "Low GI" (but less healthy in the process).

"How low on the GI scale would you like your manufactured food product, Sir? 54? 53? 41, 40? Tell me when to stop pouring"! Check out the sweet-as low GIs of high-added-fructose “Coca Cola”, "Milo", “Snickers Bar”, "Ice Cream", “Cake” in a search at http://www.glycemicindex.com/foodSearch.php .

For the low-GI industry, the good news is that the most-popular carbohydrate in our food supply – added fructose – also is pretty well the lowest-GI carbohydrate. The bad news is that a growing nucleus of global scientific opinion considers super-low-GI fructose to be the primary driver of the global obesity and diabetes epidemics (http://www.nytimes.com/2011/04/17/magazine/mag-17Sugar-t.html?pagewanted=all ).

Incentives matter, so it must be noted that the low-GI industry has a strong incentive to sound certain that sugar/fructose is not a problem, and to dismiss the idea that modern doses of super-low-GI fructose are a major driver of global obesity, diabetes and other self-inflicted “diseases of affluence”.

Is that series of errors on sugar, obesity and diabetes just clumsiness?

The likelihood that the low-GI industry would tend to contract or collapse if modern doses of super-low-GI fructose/sugar came to be viewed widely by consumers as a major health hazard represents a serious conflict of interest for the high-profile low-GI industry.

An obvious question is are those dot points above just a series of clumsy mistakes on basic facts? They could be - after all, Gary Taubes has documented extraordinary incompetence and sloppiness with key facts by some of the highest-profile and most-influential nutritionists in the US and UK over the past century (for starters, check out Chapters 6 and 23 in "Good Calories, Bad Calories").

Or are the University of Sydney's high-profile low-GI advocates actually as smart as advertised, and simply doing all they can to breathe life into the fundamentally flawed low-GI approach to nutrition, the approach to which they have devoted their careers? It's hard to know anything much until legitimate questions on this conflict-of-interest issue are answered.

In summary, sugar consumption, obesity and diabetes all have increased over the past 30 years. Thus there is no "Australian Paradox", just an idiosyncratic and unreasonable treatment - and avoidance - of the readily available data by those who coined the phrase (see #10 and #11 at http://www.australianparadox.com/ ).

One puzzle in this episode - not yet a paradox! - is why publicly funded scientists are being allowed to continue to mislead the general public on a key cause of obesity and diabetes, by continuing to defend their dodgy paper as unblemished. In my opinion, the deeply flawed "Australian Paradox" paper should be withdrawn by the University of Sydney, and the public record on sugar, obesity and diabetes corrected without further delay.

Importantly, the authors' main excuse so far - that cars not humans have been eating any rising trend in available sugar - is belied by the fact that raw sugar is NOT used as feedstock in ethanol production in Australia. This eye-popping error by JBM and AWB in response to my critique is an unmistakable confirmation that the paper's analysis is sloppy and lightweight, and its conclusion hopelessly false. Again, increased "sugar availability" and rising sugary food imports make a mockery of the University of Sydney's repeated claim that (human) sugar consumption has undergone a "substantial decline" over "the past 30 years".

Fighting obesity, diabetes and related maladies - in Aboriginal communities and elsewhere - is the biggest health issue of our time. Accordingly, it's way past time for the ham-fisted University of Sydney low-GI advocates to do the right thing and correct the public record on sugar, obesity and diabetes.

By the way, no-one yet has claimed the $40,000 up for grabs in my "Australian Paradox" challenge. Since you no doubt can tell the difference between up and down on a simple chart, why not have a lash? Full details are available at #11 at http://www.australianparadox.com/

12 months ago report
Gil Hardwick

Anthropologist

Julie, and Rory and Mark, you all know that we all know there is nothing new here. We were trying to get lolly water out of the stores 40 years ago to no avail. There is simply too much profit in them.

Rather I suggest that we focus on what is common here, not on what is different among Aboriginal people as is usually and I suggest always inappropriately the case. As you say, Mark, "not particularly different from the rest of Australia really . . ."

ALL people routinely impoverished, discouraged…
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Julie, and Rory and Mark, you all know that we all know there is nothing new here. We were trying to get lolly water out of the stores 40 years ago to no avail. There is simply too much profit in them.

Rather I suggest that we focus on what is common here, not on what is different among Aboriginal people as is usually and I suggest always inappropriately the case. As you say, Mark, "not particularly different from the rest of Australia really . . ."

ALL people routinely impoverished, discouraged, disempowered, are as routinely bored and frustrated. What are the kids in these communities doing different from kids in low SES urban environments, who likewise eat junk food, drink lolly water, sit around watching TV or playing video games, with no motivation to get out there and achieve something in their life?

Bush tucker is no solution, and I do claim some expertise in this area. Experiments of this sort have achieved nothing more than almost complete denuding of the surrounding landscape. There is no option but to provide other foods.

These obese children are not merely obese. They are also poorly motivated, develop poor cognitive skills, and suffer general ill-health. A good control group is, say, the undergraduate body in any of our universities who are inevitably slim, fit and healthy, have good muscle tone, are highly motivated, and at the same time achieve highly.

I know myself because I do it, but returning to study after an active working life rather than simply retire adds 20 years to one's life. To be able to achieve academically one needs to be fit and healthy, else the brain simply doesn't function properly.

Traditionally, Aboriginal people travelled all over the country to attend ceremonies and rituals. It had little to do with their diet, and a very great deal to do with their education and cognitive development, and their achieving status and renown.

If you like, a closer control is found in the population of fit and healthy Aboriginal people who I think you will find travel around a very great deal indeed. Some of them are serious globe trotters. I wrote my Honours thesis in Anthropology on this very coming-of-age process, back in 1989. The Marxists hated it, focussing on the young achievers rather than the 'victims', but you get that.

The more fundamental question is, anywhere in Australia, how is good nutrition packaged with shelter, proper healthcare and general education to be delivered in a way that is effective in resolving this ongoing dilemma of chronic underachievement in the population?

We can turn the question around, from the somewhat negative approach to what can we do about obesity, to the positive approach that asks rather, how can we get the kids back to school and interested in their studies, and in life generally?

12 months ago report
1. Gil Hardwick
  
  Anthropologist
  
  In reply to Gil Hardwick
  
  Just to add here, Julie, the single most successful strategy developed by the people themselves is what we call 'two roads'. Children are sent away to one of the top boarding schools during term, equivalent to what used to be known as single men's camps (or their female equivalent), then during bush holiday time going back out to visit country.
  
  It's called two roads because in it the young up-and-comers, as I have also written before, become bilingual and bicultural, later multilingual and multicultural…
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  Just to add here, Julie, the single most successful strategy developed by the people themselves is what we call 'two roads'. Children are sent away to one of the top boarding schools during term, equivalent to what used to be known as single men's camps (or their female equivalent), then during bush holiday time going back out to visit country.
  
  It's called two roads because in it the young up-and-comers, as I have also written before, become bilingual and bicultural, later multilingual and multicultural, as against the poverty-stricken by comparison Western monoculturalism. It remains sadly the case that the bulk of public general education in this country is crap, it's boring, tedious, singularly uninspiring. The best thing we can do there is fundamental educational reform taking the whole of child development into account, not simply better nutrition.
  
  Being fit and healthy is astonishingly addictive. I have never met anyone who is fit and healthy who is willing to give it up. The motivation for children to get out and run around is innate, yet we try to make them sit still for long periods then complain they are unhealthy.
  
  This process in Aboriginal Australia is well established. It's been around ever since I can remember, and I'm in my 60s now. I learned it from Top End elders, not whitefellas, a long time ago. I later studied under Prof Berndt, and thoroughly familiar with Stanner, Strehlow, Elkin, all the old-school field anthropologists who as often, like me, were also invited to participate in the ceremonies and given our own name.
  
  I add this here to point out that the problem being addressed is a human problem, not an Aboriginal problem per se. Many of the solutions already worked out in the communities have long worked best, and it does seem to me far more appropriate that we all sit and learn something from them finally. It works both ways.
  
  12 months ago report
2. Steve Brown
  
  logged in via email @yahoo.com.au
  
  In reply to Gil Hardwick
  
  "I add this here to point out that the problem being addressed is a human problem, not an Aboriginal problem per se."
  
  The problem with that reasoning is that not all humans have experienced the same things.
  
  Aboriginals were catapulted from a hunter-gatherer way of life into a modern industrial life over an extremely short time period. Most humans simply weren't introduced to such a radical disruption/transformation. The ancestors of non-indigenous Australian's had at least 10,000 years worth…
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  "I add this here to point out that the problem being addressed is a human problem, not an Aboriginal problem per se."
  
  The problem with that reasoning is that not all humans have experienced the same things.
  
  Aboriginals were catapulted from a hunter-gatherer way of life into a modern industrial life over an extremely short time period. Most humans simply weren't introduced to such a radical disruption/transformation. The ancestors of non-indigenous Australian's had at least 10,000 years worth of exposure to agriculture and the new foods it bought it with. Aboriginal people have had only a few hundred years.
  
  I would not at all be surprised to learn that Aboriginals and other indigenous people's lack of exposure -relative to europeans- to these new foods renders them more susceptible to the diseases of civilization.
  
  Even if a physiological basis can't explain the gap in health outcomes between indigenous and non-indigenous Australians, can we really say that the non-indigenous are going to face the same psychological hurdles as a group of people who were until very recently hunter-gatherers?
  
  It seems fairly obvious that such a rapid introduction to a modern industrial civilization creates the kind of existential problems for indigenous people that the rest of us won't ever be confronted with.
  
  12 months ago report
3. Matt Stevens
  
  Senior Research Fellow/Statistician/PhD
  
  In reply to Gil Hardwick
  
  YES YES YES. I too wish Australia would stop Aboriginalising the problems that occur within too much of the Aboriginal population in Australia. It simply adds to the separation and difference, rather than the commonalities. Things will change very slowly I think Gil. Living up here in the NT, you can see the public health messages slowly filtering through the Aboriginal community. For example, I remember growing up in the early 70's when it was still cool to spit. This is still common among Aboriginal communities up here, but is starting to become less common. Smoking is another one, where the rates are starting to fall, but 20-40 years after the non-indigenous population. I think there is often resistance within the Aboriginal population simply to be "different" from the white folk.
  
  3 months ago report
Steve Brown

logged in via email @yahoo.com.au

Professor Kerin O'Dea took a group of Aborigines suffering from a variety of health problems out to the bush where they consumed a traditional hunter-gatherer diet:

"We lived off the land for seven weeks and in that time, all of the metabolic abnormalities of diabetes and all of the risk factors for heart disease that I could measure just plummeted. People changed, those Aboriginal people changed completely when they went back to the bush. They were in charge of their lives. And they had this sense that we talk about now of mastery and control over their lives and we know that when people have a sense of mastery and control, they're healthier. "

http://sixtyminutes.ninemsn.com.au/stories/lizhayes/797223/backyard-revolution

12 months ago report
1. rory robertson
  
  rory robertson is a Friend of The Conversation.
  
  former fattie
  
  In reply to Steve Brown
  
  Steve, my reading of the evidence is that local population after local population across the globe tended towards obesity and diabetes - "diabesity" - soon after they started eating big amounts of refined sugar/fructose. Going the other way, your neat "60 Minutes" example demonstrates again what thousands of us have found in recent years - stop eating the sugary junk and those trends are reversed. Happily, it is that simple, because appetite control shows up within weeks of sugary junk exiting stage…
  Read more
  
  Steve, my reading of the evidence is that local population after local population across the globe tended towards obesity and diabetes - "diabesity" - soon after they started eating big amounts of refined sugar/fructose. Going the other way, your neat "60 Minutes" example demonstrates again what thousands of us have found in recent years - stop eating the sugary junk and those trends are reversed. Happily, it is that simple, because appetite control shows up within weeks of sugary junk exiting stage left. The difficulty is convincing people to take the simple step of junking added sugar/fructose. It's so tasty - and many are addicted to it (I was) - that it's hard to want to wave goodbye for keeps. Anyway, Gary Taubes's fascinating book "Good Calories, Bad Calories"provides a fascinating history of what has been good and bad in nutrition science over the past century and before, including the disastrous judgements by less than a dozen influential but ham-fisted US nutritionists who in the 1970s inadvertently fast-tracked the world's diabesity epidemic.
  
  12 months ago report
2. Matt Stevens
  
  Senior Research Fellow/Statistician/PhD
  
  In reply to Steve Brown
  
  If anyone (overweight/obese, Aboriginal or non-Aboriginal included) walked around the bush hunting and gathering food for 7 weeks, i reckon they would lose weight. There is nothing groundbreaking about this research, only the fact that it made the bleeding hearts feel better about themselves.
  
  People can empower themselves through many ways. For an Aboriginal person, it may be caring for country or it may be holding down a job and doing it well. I know which one is going to benefit the person and their family more in the long run! Do you Steve?
  
  3 months ago report

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Innovative strategies needed to address Indigenous obesity

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Mark Carter

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Gil Hardwick

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Matt Stevens

Steve Brown

rory robertson

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