Australia: the healthiest country by 2020
National Preventative Health Strategy – the roadmap for action

Key action area 9: Reduce obesity prevalence and burden among Indigenous Australians

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Among Aboriginal and Torres Strait Islander people, high body mass is the second highest contributor to disease burden (11.4%), after tobacco use (12.1%).[188] In comparison, among the general Australian population, high body mass is the third highest contributor to disease burden (7.5%), after tobacco use (7.8%) and high blood pressure (7.6%).[11]

In 2004–05, approximately 60% of Indigenous Australians aged 18 years and over were overweight, of whom 31% were obese.[7] Indigenous Australians were:¹⁵

• 1.9 times as likely to be obese
• Over three times as likely to be morbidly obese (BMI >40)[7]

The proportion of the health gap attributable to alcohol, tobacco and obesity is also distributed unevenly. While Indigenous people in remote areas make up 26% of the total Indigenous population, they contribute 38% of the health gap due to high body mass.[189]

Nutrition-related health and Indigenous Australians

'The enormous inequity in food availability and affordability for Indigenous Australians alone is a very fundamental issue to be addressed if there is any hope of 'Closing the Gap' (Quote from submission)

The majority (75%) of Indigenous Australians live in urban areas, while 25% live in remote communities. Reflecting this distribution, those living in urban areas constitute 60% of the health gap. Therefore strategies to improve Indigenous health must include a focus on rural, remote and urban communities.[189]

Diet has been indicated as a risk factor in 57% of all deaths in Australia, based on Australian Bureau of Statistics (ABS) deaths data in 1983.[190] Many of the main causes of ill health among Aboriginal and Torres Strait Islander peoples are nutrition-related conditions, such as heart disease, type 2 diabetes and renal disease.[191]

Recent Aboriginal and Torres Strait Islander-specific health data[191] indicate that the majority of Aboriginal and Torres Strait Islander peoples aged 12+ years reported some daily intake of vegetables (95%) and/or fruit (86%). Access to such fresh food may be more difficult for Aboriginal and Torres Strait Islander peoples in remote areas, as one in five (20%) of those living in remote areas reported no usual daily fruit intake compared with one in eight (12%) in non-remote areas. This difference was even greater for vegetables: 15% of people in remote areas reported no usual daily intake compared with 2% in non-remote areas.

Among those living in non-remote areas, 42% were eating the recommended daily intake of fruit and 10% the recommended daily intake of vegetables. While the intake of vegetables was broadly similar between Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander peoples, Aboriginal and Torres Strait Islander people generally reported eating less fruit than non-Aboriginal and Torres Strait Islander people. These questions were not recorded for remote and urban locations.[191]
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Physical activity and health of Indigenous Australians

The rationale for increasing the focus on physical activity among Aboriginal and Torres Strait Islander people is compelling. In 2004–05, information was collected relating to the frequency, intensity and duration of exercise undertaken by Aboriginal and Torres Strait Islander people living in non-remote areas. The proportion of Aboriginal and Torres Strait Islander people in non-remote areas who were sedentary or engaged in low-level exercise in the two weeks prior to interview was higher in 2004–05 (75%) than in 2001 (68%).[191] In 2001 around 43% of Aboriginal and Torres Strait Islander adults living in remote areas reported no leisure-time physical activity, compared to about 30% of other Australians in the same areas.[192]

Recreation, fitness, sports, active living, access to parks, arts and culture all contribute to social and emotional wellbeing, enhanced quality of life, fine motor skill development, overall health and weight control.[193]

Key actions to reduce the burden of obesity among Indigenous Australians

Key specific actions to reduce the high burden of disease due to obesity among Indigenous Australians include resourcing of interventions from the primary healthcare setting; strengthening antenatal, maternal and child health systems for Indigenous communities; and implementing multi-component community-based programs.[189]

Interventions from the primary healthcare setting

Brief interventions on diet and exercise have been shown to be effective in the mainstream community to decrease fat consumption, increase fibre consumption and increase physical activity.[194, 195] There is no evaluated evidence specific to the Australian Indigenous context. Brief intervention programs for physical activity and nutrition for Aboriginal and Torres Strait Islander peoples are being piloted in Queensland,¹⁶ with future impact and outcome evaluation to be included in service expansion.

Successful interventions are likely to be dependent on the same factors as for alcohol and tobacco: adequate resourcing to allow a focus on non-acute issues, training, public health expertise on staff, and quality improvement systems. Follow-up sessions to the initial consultation are critical to improvements over the long term.[195]


Notwithstanding the powerful effects of social determinants of health such as relative and absolute poverty, lack of education and powerlessness, a well-resourced and robust primary healthcare has significant potential to contribute to closing the Indigenous health gap.[189]
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Antenatal, maternal and child health services

Poor nutrition in the first years of life and low birth weight are associated with lifetime higher rates of overweight and obesity, and increased risk of chronic disease later in life.[196] Well-resourced and best-practice antenatal, maternal and child health services are a core component of comprehensive primary healthcare, and should include antenatal care, encouragement and support of breastfeeding, programs to monitor infant growth and development, support and advice to parents about child nutrition, and child growth monitoring and action. All primary healthcare services serving Indigenous communities should be resourced to deliver such services as a critical investment in future health.

There are numerous examples of health services that have acted on maternal and child health effectively, including Central Australian Aboriginal Congress, the Townsville Aboriginal and Islander Health Service, Nganampa Health Council, Maari Ma Health Aboriginal Corporation and the Northern Territory Government's Strong Women, Strong Babies, Strong Culture.

Multi-component community-based healthy lifestyle programs

'Healthy lifestyle' programs have been shown to be effective in the Australian Indigenous context in improving biochemical markers of chronic disease risk and health indicators,[197-200] and effective in overseas Indigenous populations in increasing physical activity.[201]

There are lessons to be learned from some interesting examples of interventions targeting Indigenous communities that are currently being implemented in Queensland. For example, Living Strong is a healthy lifestyle program for Aboriginal and Torres Strait Islander communities.¹⁷ Process evaluation has guided the development of the program, while impact and outcome evaluation is still to be conducted.

Depending on local community priority and capacity, possible areas for action in community-based health programs include nutrition, the availability and affordability of healthy food (for example, at community stores), and physical activity. Increasing opportunities for activity could include subsidised, affordable access to gyms, swimming pools and sporting facilities.[189] Ensuring that the physical and social environment in Indigenous communities is conducive to safe participation in physical activity would need to be addressed, along with providing participation opportunities for Aboriginal and Torres Strait Islander children at school and at home, including physical education at school.[49]

Possible models for implementation to maximise the affordability and availability of fresh food in remote areas include the Outback Stores program set up by the Australian Government in 2006, now running in stores across the Northern Territory and in Western Australia, and the subsidisation of fresh food costs in remote areas.[202]

It is also important to note the strong evidence that outstation living and access to traditional lands is associated with reduced risk of obesity, improved physical health and overall lower chronic disease risk and mortality.[203-207]
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The cost of food

Australians living in rural and remote areas are among those at particular risk of food insecurity.[72] In 2006 a healthy food basket cost on average 29% more (ranging from 24% to 56%) in remote areas of the Northern Territory compared with Darwin.[208]

A study in a remote Northern Territory Indigenous community found that food in general cost 50% more than in Darwin, and that families spent an average of 38% of their income on food and non-alcoholic beverages, compared with 14% for the average Australian household and 30% for low-income non-remote Australian households.[208]

At least 44% of household income and significant changes in purchasing patterns would be required to achieve dietary recommendations. While community members reported a preference for fresh produce, more than half the average energy intake in the community came from white bread and flour, sugar and milk powder, products that provide most calories for least cost, store well and divert hunger. However, when factors including store management and leadership, workforce development and improved infrastructure were addressed through a 'whole of store' approach, sales of fruit and fresh vegetables increased. Thus, while still facing significant economic barriers, people in the community purchased more fruit and vegetables when given the opportunity.[208]

The actions recommended in this strategy to address the availability of fresh food will have a positive impact on Indigenous communities in regional and remote locations. Strategies to improve access to healthy foods among rural and remote Indigenous Australians include:

• The provision of vouchers to buy a weekly basket of nutritious foods
• The examination of patterns of transport and marketing to reduce barriers to the trade of fresh local foods
• The support of economic development opportunities such as agriculture and horticulture, and the development of traditional food resources
• The provision of adequate remote food storage infrastructure
• The development of the Indigenous workforce in remote and rural stores[208]

It is critical to ensure the implementation and maintenance of relevant recommendations from the National Indigenous Health Equality Summit,¹⁸ including targeting healthy living practices such as the ability to store, prepare and cook food being available in three-quarters of all houses by 2013.[209] Poor-quality diet in the Indigenous population is a significant risk factor for three of the major causes of death (cardiovascular disease, cancer and type 2 diabetes).[210] Poor nutrition among many Indigenous people is associated with disadvantaged socioeconomic circumstances.

Interventions among Indigenous communities

There is a lack of well-evaluated nutrition, physical activity and heath programs for Aboriginal and Torres Strait Islander peoples.[211] The results of research in remote Aboriginal and Torres Strait Islander communities of Australia indicate that community-directed nutrition programs, addressing both food supply and demand issues, can clearly improve a range of risk factors for chronic disease and that improvements can be maintained.[212-215] A decrease in the prevalence of low birth weight children has been seen in Aboriginal and Torres Strait Islander communities associated with the implementation of culturally appropriate maternal and child health and nutrition programs.[216, 217]

Community involvement, management and ownership have been identified as essential components of any program promoting health in Aboriginal and Torres Strait Islander peoples, including those addressing overweight and healthy lifestyles.[211]
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Action 9.1
Fund, implement and promote effective 
and relevant strategies and programs to address specific issues experienced by people in Indigenous communities, such as lack of access to affordable, high-quality fresh food.

Action 9.2
Strengthen antenatal, maternal and child health systems for Indigenous communities.

Action 9.3
Fund, implement and promote multi-component community-based programs in Indigenous communities.

¹⁵ Based on results of the 2004–05 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) and adjusting for differences in the age structure of the Indigenous and non-Indigenous 15. populations and survey non-response for height and weight measurements.
¹⁶ For example, see www.health.qld.gov.au/ph/ documents/pdu/phstratdir_chronic.pdf.
¹⁷ For example, see www.health.qld.gov.au/ph/ documents/pdu/phstratdir_chronic.pdf.
¹⁸ On 18–20 March 2008, the National Indigenous Health Equality Summit was held in Canberra. The outcome was a statement of intent and a report detailing a series of targets aimed at achieving health status and life expectancy equality between Indigenous and non- Indigenous Australians by 2030. In December 2007 the Council of Australian Governments (COAG) agreed to a partnership between all levels of government to 'Close the Gap' on Indigenous disadvantage; notably, to close the 17-year gap in life expectancy within a generation and to halve the mortality rate of Indigenous children within 10 years. The report is available at www.hreoc. gov.au/social_Justice/health/targets/index.html.

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