Nutrition in remote Aboriginal communities: lessons from Mai Wiru and the Anangu Pitjantjatjara Yankunytjatjara Lands

Benchmarking for healthy food stores: protocol for a randomised controlled trial with remote Aboriginal and Torres Strait Islander communities in Australia to enhance adoption of health-enabling store policy and practice

BACKGROUND

Aboriginal and Torres Strait Islander communities in remote Australia have initiated bold policies for health-enabling stores. Benchmarking, a data-driven and facilitated 'audit and feedback' with action planning process, provides a potential strategy to strengthen and scale health-enabling best-practice adoption by remote community store directors/owners. We aim to co-design a benchmarking model with five partner organisations and test its effectiveness with Aboriginal and Torres Strait Islander community stores in remote Australia.

METHODS

Study design is a pragmatic randomised controlled trial with consenting eligible stores (located in very remote Northern Territory (NT) of Australia, primary grocery store for an Aboriginal community, and serviced by a Nutrition Practitioner with a study partner organisation). The Benchmarking model is informed by research evidence, purpose-built best-practice audit and feedback tools, and co-designed with partner organisation and community representatives. The intervention comprises two full benchmarking cycles (one per year, 2022/23 and 2023/24) of assessment, feedback, action planning and action implementation. Assessment of stores includes i adoption status of 21 evidence-and industry-informed health-enabling policies for remote stores, ii implementation of health-enabling best-practice using a purpose-built Store Scout App, iii price of a standardised healthy diet using the Aboriginal and Torres Strait Islander Healthy Diets ASAP protocol; and, iv healthiness of food purchasing using sales data indicators. Partner organisations feedback reports and co-design action plans with stores. Control stores receive assessments and continue with usual retail practice. All stores provide weekly electronic sales data to assess the primary outcome, change in free sugars (g) to energy (MJ) from all food and drinks purchased, baseline (July-December 2021) vs July-December 2023.

DISCUSSION

We hypothesise that the benchmarking intervention can improve the adoption of health-enabling store policy and practice and reduce sales of unhealthy foods and drinks in remote community stores of Australia. This innovative research with remote Aboriginal and Torres Strait Islander communities can inform effective implementation strategies for healthy food retail more broadly.

TRIAL REGISTRATION

ACTRN12622000596707, Protocol version 1.

Small for gestational age and anthropometric body composition from early childhood to adulthood: the Aboriginal Birth Cohort study

Background

In Australia the estimated rate of small for gestational age (SGA) births is 9% among non-Indigenous births compared to 14% among Aboriginal and Torres Strait Islanders. There is limited research investigating the effect of being born SGA on body composition later in life in Indigenous Australians.

Methods

Using data from the Aboriginal Birth Cohort longitudinal study, we compared the body composition of those born SGA to non-SGA by analysing anthropometric measures (height, weight, waist circumference, fat percentage [FAT%], body mass index [BMI], waist-to-height ratio, and A body shape index [ABSI]) collected at four follow-up periods (from childhood to adult). For cross-sectional analyses, linear regression models were employed to assess factors associated with anthropometric measures. For longitudinal analyses linear mixed models were employed to assess differences in anthropometric measures among SGA versus non-SGA individuals while adjusting for repeated measures.

Results

The analytic baseline cohort were those who participated in Wave 2 (n = 570). In cross-sectional analyses, across all waves those born SGA had smaller anthropometric z-scores compared to non-SGA individuals (β ranging from -0.50 to -0.25). Participants residing in urban environments were significantly larger in Waves 2 to 4 (β ranged 0.26 to 0.65). Those born SGA had higher ABSI scores in Waves 2 and 4 (β 0.26 and 0.37, respectively). In longitudinal analyses, those born SGA had smaller measures of body composition across the life course; these differences were larger in urban communities. In remote communities those born SGA had significantly higher ABSI scores during adolescence and young adulthood, and this difference was not observed in urban communities.

Conclusion

Indigenous Australians born SGA are smaller anthropometrically later in life compared to their non-SGA counterparts. In remote communities, those born SGA had higher levels of central adiposity compared to non-SGA.

Improving economic access to healthy diets in first nations communities in high-income, colonised countries: a systematic scoping review

BACKGROUND

Affordability of healthy food is a key determinant of the diet-related health of First Nations Peoples. This systematic scoping review was commissioned by the Ngaanyatjarra Pitjantjatjara Yankunytjatjara Women's Council (NPYWC) in Central Australia to identify interventions to improve economic access to healthy food in First Nations communities in selected high-income, colonised countries.

METHODS

Eight databases and 22 websites were searched to identify studies of interventions and policies to improve economic access to healthy food in First Nations communities in Australia, Canada, the United States or New Zealand from 1996 to May 2022. Data from full text of articles meeting inclusion criteria were extracted to a spreadsheet. Results were collated by descriptive synthesis. Findings were examined with members of the NPYWC Anangu research team at a co-design workshop.

RESULTS

Thirty-five publications met criteria for inclusion, mostly set in Australia (37%) or the US (31%). Interventions (n = 21) were broadly categorised as price discounts on healthy food sold in communities (n = 7); direct subsidies to retail stores, suppliers and producers (n = 2); free healthy food and/or food vouchers provided to community members (n = 7); increased financial support to community members (n = 1); and other government strategies (n = 4). Promising initiatives were: providing a box of food and vouchers for fresh produce; prescriptions for fresh produce; provision/promotion of subsidised healthy meals and snacks in community stores; direct funds transfer for food for children; offering discounted healthy foods from a mobile van; and programs increasing access to traditional foods. Providing subsidies directly to retail stores, suppliers and producers was least effective. Identified enablers of effective programs included community co-design and empowerment; optimal promotion of the program; and targeting a wide range of healthy foods, particularly traditional foods where possible. Common barriers in the least successful programs included inadequate study duration; inadequate subsidies; lack of supporting resources and infrastructure for cooking, food preparation and storage; and imposition of the program on communities.

CONCLUSIONS

The review identified 21 initiatives aimed at increasing affordability of healthy foods in First Nations communities, of which six were deemed promising. Five reflected the voices and experiences of members of the NPYWC Anangu research team and will be considered by communities for trial in Central Australia. Findings also highlight potential approaches to improve economic access to healthy foods in First Nations communities in other high-income colonised countries.

TRIAL REGISTRATION

PROSPERO CRD42022328326.

Towards healthy food retail: An assessment of public health nutrition workforce capacity to work with stores

OBJECTIVE

This article aims to investigate the capacity of nutrition professionals to engage in food retail practice change to improve population diet.

METHODS

Convergent mixed method design was used that includes pre-interview surveys, in-depth interviews, and retrospective mapping of service provision. The study was conducted in organisations that provide a nutrition professional service to food retail stores in remote Australia. The study participants include 11 nutrition professionals and eight organisation representatives, including managers, organisation directors and policy officers. Systems-mapping and thematic analysis of the in-depth interviews were conducted using a capacity development framework. Descriptive analysis was applied to pre-interview survey and mapping data.

RESULTS

A gap between the aspirational work and current capacity of nutrition professionals to engage effectively with stores was identified. Engagement with stores to improve population health was valued by organisations. Dominance of the medical health model limited organisation strategic support for store work and created barriers. Key barriers included the limited access to training, decision-support tools, information, financial resources and organisational structures that directed store work.

CONCLUSIONS

Provision of adequate store-specific training, resources and organisational support may empower the nutrition professional workforce to be powerful leaders in co-design for healthy food retail.

IMPLICATIONS FOR PUBLIC HEALTH

Building capacity for this critical workforce to engage in food retail practice change must consider the influence of the broader health system and employer organisations and need for access to evidence-based decision-support tools.

Seeking Sweetness: A Systematic Scoping Review of Factors Influencing Sugar-Sweetened Beverage Consumption in Remote Indigenous Communities Worldwide

It is well-established that remote Indigenous communities have higher rates of sugar-sweetened beverage (SSB) consumption than non-Indigenous counterparts, which results in higher rates of chronic diseases such as type 2 diabetes mellitus (T2DM), obesity, and kidney disease. The aetiology leading to this behaviour remains understudied and overlooked. Therefore, the aim of this literature review is to understand the underpinning factors that contribute to SSB consumption in remote Indigenous communities. Studies were identified through five databases (n = 2529) and grey literature searching (n = 54). Following the PRISMA guidelines, each paper was assessed for eligibility, which left 34 studies for inclusion in the review. Within these papers, 37 different factors were found to influence SSB consumption in remote Indigenous communities. These were organised according to the Determinants of Nutrition and Eating (DONE) framework. SSB consumption was found to influence intake through each main level of the framework; individual (n = 9), interpersonal (n = 18), environmental (n = 9), and policy (n = 3). Preference was identified to be the most common factor to influence intake (n = 19), followed by health literacy (n = 15) and community availability (n = 12). Despite this, interventions to reduce SSB intake have never targeted this factor. This paper highlights the importance of a multi-level whole-of-system approach and suggests that an individual’s taste/preference should shape the direction of future research and intervention in this area.

Costing recommended (healthy) and current (unhealthy) diets in urban and inner regional areas of Australia using remote price collection methods

OBJECTIVE

To compare the cost and affordability of two fortnightly diets (representing the national guidelines and current consumption) across areas containing Australia's major supermarkets.

DESIGN

The Healthy Diets Australian Standardised Affordability and Pricing protocol was used.

SETTING

Price data were collected online and via phone calls in fifty-one urban and inner regional locations across Australia.

PARTICIPANTS

Not applicable.

RESULTS

Healthy diets were consistently less expensive than current (unhealthy) diets. Nonetheless, healthy diets would cost 25-26 % of the disposable income for low-income households and 30-31 % of the poverty line. Differences in gross incomes (the most available income metric which overrepresents disposable income) drove national variations in diet affordability (from 14 % of the median gross household incomes in the Australian Capital Territory and Northern Territory to 25 % of the median gross household income in Tasmania).

CONCLUSIONS

In Australian cities and regional areas with major supermarkets, access to affordable diets remains problematic for families receiving low incomes. These findings are likely to be exacerbated in outer regional and remote areas (not included in this study). To make healthy diets economically appealing, policies that reduce the (absolute and relative) costs of healthy diets and increase the incomes of Australians living in poverty are required.

Interventions to address food insecurity among Aboriginal and Torres Strait Islander people: a rapid review

Food insecurity disproportionately impacts Aboriginal and Torres Strait Islander Australians. This review sought to investigate research and evaluations of programs and interventions implemented to address food insecurity among Aboriginal and Torres Strait Islander communities. A rapid review was conducted to collate the available research from 6 databases. The search was conducted in May 2020. Search constructs related to food insecurity, Aboriginal and Torres Strait Islander people, and Australia. Twenty-five publications were included in this review, 24 reported on an intervention, while 9 were evaluations of an intervention. Interventions included behaviour change projects, including projects that sought to change purchasing and cooking behaviours, school-based education programs, and gardening programs. In general, the studies included in this sample were small and lacked a systematic consideration of the factors that shape the experience of food insecurity among Aboriginal and Torres Strait Islander people specifically. Based on the findings of this review, authors suggest greater consideration to the systematic determinants of food insecurity among Aboriginal and Torres Strait Islander communities to have lasting and sustainable impact on food insecurity. This review has been registered with the international prospective register of systematic reviews (PROSPERO: CRD42020183709). Novelty: Food insecurity among Aboriginal and Torres Strait Islander people poses significant risk to health and wellbeing. Small-scale food security interventions may not provide ongoing and sustained impact. Any intervention to promote food security will need to involve Aboriginal and Torres Strait Islander people and be sustained once external parties have left.

Sugar sweetened beverages and increasing prevalence of type 2 diabetes in the Indigenous community of Australia

AIMS

The aim of this viewpoint was to discuss a profound health gap in type 2 diabetes that exists between Indigenous and non-Indigenous Australians.

DATA SYNTHESIS

In Australia, type 2 diabetes is ranked as the fastest growing chronic condition, with the rates of type 2 diabetes higher among Indigenous than non-Indigenous Australians. Improvements to diet could aid in reducing overweight and obesity in the Indigenous community, with sugar sweetened beverages (SSBs) examples of discretionary foods that contain a high amount of sugar. The marked increase in type 2 diabetes, obesity and consumption of SSBs in the Indigenous community may suggest that type 2 diabetes may result from weight gain caused by SSB consumption. Recent evidence suggests that higher consumption of SSBs was associated with greater incidence of type 2 diabetes independent of adiposity. Some determinants influencing increased SSBs consumption in the Indigenous population include advertising, marketing, availability and affordability.

CONCLUSIONS

The prevalence rates of type 2 diabetes continue to be higher among Indigenous than non-Indigenous Australians and overall, a link between SSBs and risk of type 2 diabetes is reported. Three solutions to high SSBs consumption in Indigenous communities include increased availability, affordability, and accessibility of healthy food and drink, engagement of Indigenous people in offering solutions including discussion of a sugar tax on SSBs framed with Indigenous input, and the provision of clean community water supply and water bubblers.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia.

STUDY DESIGN

Rapid review of articles published between January 2000 and May 2020.

DATA SOURCES

We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries.

DATA SYNTHESIS

Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding.

CONCLUSION

Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries.

STUDY DESIGN

We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references.

DATA SOURCES

We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence.

DATA SYNTHESIS

Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle.

CONCLUSION

There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia.

STUDY DESIGN

Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews.

DATA SOURCES

We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria.

DATA SYNTHESIS

Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma.

CONCLUSION

We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities.

STUDY DESIGN

Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km² .

DATA SOURCES

We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway.

DATA SYNTHESIS

We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3).

CONCLUSION

Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce.

STUDY DESIGN

We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool.

DATA SOURCES

We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites.

DATA SYNTHESIS

During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool.

CONCLUSION

We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings.

STUDY DESIGN

Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards.

DATA SOURCES

English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing, deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar.

DATA SYNTHESIS

Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation.

CONCLUSION

Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

How Neoliberalism Shapes Indigenous Oral Health Inequalities Globally: Examples from Five Countries

Evidence suggests that countries with neoliberal political and economic philosophical underpinnings have greater health inequalities compared to less neoliberal countries. But few studies examine how neoliberalism specifically impacts health inequalities involving highly vulnerable populations, such as Indigenous groups. Even fewer take this perspective from an oral health viewpoint. From a lens of indigenous groups in five countries (the United States, Canada, Australia, Aotearoa/New Zealand and Norway), this commentary provides critical insights of how neoliberalism, in domains including colonialism, racism, inter-generational trauma and health service provision, shapes oral health inequalities among Indigenous societies at a global level. We posit that all socially marginalised groups are disadvantaged under neoliberalism agendas, but that this is amplified among Indigenous groups because of ongoing legacies of colonialism, institutional racism and intergenerational trauma.

Maitjara Wangkanyi: Insights from an Ethnographic Study of Food Practices of Households in Remote Australian Aboriginal Communities

Many historical, environmental, socioeconomic, political, commercial, and geographic factors underscore the food insecurity and poor diet-related health experienced by Aboriginal people in Australia. Yet, there has been little exploration of Aboriginal food practices or perspectives on food choice recently. This study, with 13 households in remote communities on the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands, fills this gap using ethnographic and Indigenist methods. Results highlight Anangu resourcefulness, securing food despite poverty and adversity, and provide unique insights into factors influencing the three major types and range of dietary patterns identified. These factors include household economic cycles and budgeting challenges; overcrowding and family structures, mobility and ‘organization’; available food storage, preparation and cooking infrastructure; and familiarity and convenience. Structural and systemic reform, respecting Aboriginal leadership, is required to improve food security.

Effect of restricted retail merchandising of discretionary food and beverages on population diet: a pragmatic randomised controlled trial

BACKGROUND

The effectiveness of healthy food promotion on food and beverage sales in real-world food retail settings has been shown in randomised trials. The effectiveness of restrictions on the promotion of unhealthy food is, however, less clear. We aimed to assess the effect of restricted unhealthy food promotion, specifically those items contributing most to free sugar sales, on food and beverage sales.

METHODS

In this community-level pragmatic, partially randomised, parallel group trial, stores were randomly assigned by a statistician using a single sequence of random assignments to the intervention group, in which a co-designed strategy restricted merchandising of unhealthy food, or to a control group of usual retail practice. The trial was done in partnership with an organisation operating 25 stores in remote Australia. The primary analysis was based on difference in weekly sales with the strategy compared with no strategy in free sugar from all foods and beverages (g/total MJ; primary outcome), targeted food or beverages (weight and free sugars; g/total MJ), and gross profit (AU$) using mixed models. This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001588280.

FINDINGS

Between June 13 and Aug 15, 2018, 20 stores were recruited; ten stores were randomly assigned to the intervention group and ten stores to the control group. The trial was done between Sept 2 and Dec 2, 2018. The Healthy Stores 2020 strategy resulted in a reduction in sales of free sugar of 2·8% (95% CI -4·9 to -0·7). Targeted beverages were reduced by 8·4% (-12·3 to -4·3) and associated free sugar by 6·8% (-10·9 to -2·6), sugar-sweetened soft drinks by 13·2% (-18·5 to -7·6), and associated free sugar by 13·4% (-18·7 to -7·7). Reductions in sales of free sugar from confectionery of 7·5% (-14·3 to -0·2) and in weight sold (-4·6%, -11·1 to 2·3) resulted; however, the reduction in weight was not statistically significant. No differences in sales of table sugar and sweet biscuits were observed. Gross profit was not impacted adversely; a small increase resulted (5·3%, 0·3 to 10·5).

INTERPRETATION

Restricted merchandising of unhealthy foods and beverages, while allowing for complementary merchandising of healthier foods and beverages in a real-world store setting and co-designed with retailers, can achieve both public health and business relevant gains.

FUNDING

Australian National Health and Medical Research Council.

The Retail Food Environment, Store Foods, and Diet and Health among Indigenous Populations: a Scoping Review

PURPOSE OF THE REVIEW

Describe the state of knowledge on how the retail food environment contributes to diet-related health and obesity among Indigenous populations, and assess how the literature incorporates Indigenous perspectives, methodologies and engagement throughout the research process. Outcomes included dietary behaviour (purchasing, intakes and diet quality) and diet-related health outcomes (weight-related outcomes, non-communicable diseases and holistic health or definitions of health as defined by Indigenous populations involved in the study).

RECENT FINDINGS

Of fifty included articles (1996-2019), the largest proportions described Indigenous communities in Canada (20 studies, 40%), the USA (16, 32%) and Australia (9, 18%). Among articles that specified the Indigenous population of focus (42 studies, 84%), the largest proportion (11 studies, 26%) took place in Inuit communities, followed by Aboriginal and Torres Strait Islander communities (8 studies, 19%). The included literature encompassed four main study designs: type A, dietary intakes of store foods (14 studies, 28%), and type B, store food environments (16, 32%), comprised the greatest proportion of articles; the remainder were type C, store food environments and diet (7, 14%), and type D, store food environment interventions (13, 26%). Of the studies that assessed diet or health outcomes (36, 72%), 22 (61%) assessed dietary intakes; 16 (44%) sales/purchasing; and 8 (22%) weight-related outcomes. Store foods tended to contribute the greatest amount of dietary energy to the diets of Indigenous peoples and increased non-communicable disease risk as compared to traditional foods. Multi-pronged interventions appeared to have positive impacts on dietary behaviours, food purchasing and nutrition knowledge; promotion and nutrition education alone had more mixed effects. Of the nine studies which were found to have strong engagement with Indigenous populations, eight had moderate or high methodological quality. Eighteen studies (36%) did not mention any engagement with Indigenous populations. The literature confirmed the importance of store foods to the total energy intake of the contemporary diets of Indigenous people, the gaps in accessing both retail food environments and traditional foods and the potential for both new dietary assessment research and retail food environment intervention strategies to better align with and privilege Indigenous Ways of Knowing.

Development and pilot of a tool to measure the healthiness of the in-store food environment

Objective:

To rigorously develop a tool which enables rapid yet comprehensive appraisal of the consumer food retail environment and provision of real-time feedback to store managers and owners, based on the ‘4Ps’ principles of marketing.

Design:

Multi-stage iterative approach including (1) Systematic literature review; (2) Stakeholder consultation; (3) Assessment of existing tools against identified needs; (4) Tool development; (5) Pilot testing and (6) Transition of tool to mobile application (the Store Scout app).

Setting:

Northern Territory, Australia.

Participants:

Nine remote Aboriginal community food stores; public health nutritionists, retailers, store board directors, Aboriginal community members, government representatives.

Results:

Forty-seven existing tools and thirty-four stakeholder interviews informed the development of the current instrument, which comprised: (1) seven product categories (Fruit & Vegetables, Drinks, Snack Foods, Meals & Convenience Foods, Meat & Seafood, Dairy & Eggs, Breads & Cereals) across the ‘4Ps’ (Product, Placement, Price, Promotion); (2) Store manager questions about context and perceived importance of key principles about the store environment and (3) a scoring and feedback component. The tool was considered feasible and acceptable by all testers.

Conclusions:

The developed tool addresses an unmet need to measure the consumer food retail environment across all 4Ps whilst also incorporating manager perspectives and immediate feedback. Our objectives of developing a comprehensive, feasible and acceptable instrument were achieved during pilot testing. The tool will support implementation of best practice within stores to encourage healthy food choices and has potential for broad application in retail settings locally and internationally, as well as for research purposes.

Effects of food policy actions on Indigenous Peoples' nutrition-related outcomes: a systematic review

INTRODUCTION

Indigenous Peoples worldwide endure unacceptable health disparities with undernutrition and food insecurity often coexisting with obesity and chronic diseases. Policy-level actions are required to eliminate malnutrition in all its forms. However, there has been no systematic synthesis of the evidence of effectiveness of food and nutrition policies for Indigenous Peoples around the world. This review fills that gap.

METHODS

Eight databases were searched for peer-reviewed literature, published between 2000 and 2019. Relevant websites were searched for grey literature. Articles were included if they were original studies, published in English and included data from Indigenous Peoples from Western colonised countries, evaluated a food or nutrition policy (or intervention), and provided quantitative impact/outcome data. Study screening, data extraction and quality assessment were undertaken independently by two authors, at least one of whom was Indigenous. A narrative synthesis was undertaken with studies grouped according to the NOURISHING food policy framework.

RESULTS

We identified 78 studies from Canada, Australia, Aotearoa/New Zealand and the USA. Most studies evaluated targeted interventions, focused on rural or remote Indigenous communities. The most effective interventions combined educational strategies with policies targeting food price, composition and/or availability, particularly in retail and school environments. Interventions to reduce exposure to unhealthy food advertising was the only area of the NOURISHING framework not represented in the literature. Few studies examined the impact of universal food policies on Indigenous Peoples' diets, health or well-being.

CONCLUSION

Both targeted and universal policy action can be effective for Indigenous Peoples. Actions that modify the structures and systems governing food supply through improved availability, access and affordability of healthy foods should be prioritised. More high-quality evidence on the impact of universal food and nutrition policy actions for Indigenous Peoples is required, particularly in urban areas and in the area of food marketing.

A systematic review of the Australian food retail environment: Characteristics, variation by geographic area, socioeconomic position and associations with diet and obesity

There is strong support across multiple sectors for the implementation of policies to create healthier food environments as part of comprehensive strategies to address obesity and improve population diets. The existing evidence base describing food retail environments and their relationship with health outcomes is limited in several respects. This systematic review examines the current evidence regarding food retail environments in Australia, including associations with diet and people with obesity, and socioeconomic and geographic disparities. Three databases were searched and independently screened. Studies were included if they were undertaken in Australia and objectively measured the food retail environment. Sixty papers were included. The broad range of methodological approaches used across studies limited the ability to synthesize the evidence and draw conclusions. Results indicated that there is some evidence that disparities exist in food retail environments across measures of socioeconomic position and geographic area in parts of Australia. Overall, there were inconsistent findings regarding the association between the healthiness of food retail environments and diet or people with obesity. Findings support previous calls for standardized tools and measures for monitoring the healthiness of food retail environments. This is imperative to inform evidence-based policy and evaluation in this critical component of recommended obesity prevention strategies.

Reducing Retail Merchandising of Discretionary Food and Beverages in Remote Indigenous Community Stores: Protocol for a Randomized Controlled Trial

Background

Discretionary food and beverages (products high in saturated fat, added sugars, and salt) are detrimental to a healthy diet. Nevertheless, they provide 42% of total energy and account for 53% of food and beverage expenditure for remote living Aboriginal and Torres Strait Islander Australians, contributing to the excessive burden of chronic diseases experienced by this population group.

Objective

The aim of this study is to test an intervention to reduce sales of discretionary products, in collaboration with the Arnhem Land Progress Aboriginal Corporation (ALPA), which operates 25 stores in very remote Australia, by reducing their merchandising and substituting with core products in remote Australian communities.

Methods

We will use a community-level randomized controlled pragmatic trial design. Stores randomized to the intervention group will be supported by ALPA to reduce merchandising of 4 food categories (sugar, sugar-sweetened beverages, sweet biscuits, and confectionery) that together provide 64% of energy from discretionary foods and 87% of total free sugars in very remote community stores. The remaining stores (50% of total) will serve as controls and conduct business as usual. Electronic store sales data will be collected at baseline, 12-weeks intervention, and 24-weeks postintervention to objectively assess the primary outcome of percent change in purchases of free sugars (g/megajoule) and secondary business- and diet-related outcomes. Critical to ensuring translation to improved store policies and healthier diets in remote Indigenous Australia, we will conduct (1) an in-depth implementation evaluation to assess fidelity, (2) a customer intercept survey to investigate the relationship between customer characteristics and discretionary food purchasing, and (3) a qualitative study to identify policy supports for scale-up of health-enabling policy action in stores.

Results

As of August 2018, 20 stores consented to participate and were randomized to receive the intervention or continue usual business. The 12-week strategy ended in December 2018. The 24-week postintervention follow-up will occur in May 2019. Trial results are expected for 2019.

Conclusions

Novel pragmatic research approaches are needed to inform policy for healthy retail food environments. This research will greatly advance our understanding of how the retail food environment can be used to improve population-level diet in the remote Australian Aboriginal and Torres Strait Islander context and retail settings globally.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618001588280; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375933 (Archived by WebCite at http://www.webcitation.org/76dbQEmwN)

International Registered Report Identifier (IRRID)

DERR1-10.2196/12646

Sugar-sweetened beverage (SSB) consumption, correlates and interventions among Australian Aboriginal and Torres Strait Islander communities: a scoping review

OBJECTIVES

Sugar-sweetened beverage (SSB) consumption in Australian Aboriginal and Torres Strait Islander people is reported to be disproportionally high compared with the general Australian population. This review aimed to scope the literature documenting SSB consumption and interventions to reduce SSB consumption among Australian Aboriginal and Torres Strait Islander people. Findings will inform strategies to address SSB consumption in Aboriginal and Torres Strait Islander communities.

METHODS

PubMed, SCOPUS, CINAHL, Informit, Joanna Briggs Institute EBP, Mura databases and grey literature were searched for articles published between January 1980 and June 2018. Studies were included if providing data specific to an Australian Aboriginal and/or Torres Strait Islander population's SSB consumption or an intervention that focused on reducing SSB consumption in this population.

DESIGN

Systematic scoping review.

RESULTS

59 articles were included (1846 screened). While reported SSB consumption was high, there were age-related and community-related differences observed in some studies. Most studies were conducted in remote or rural settings. Implementation of nutrition interventions that included an SSB component has built progressively in remote communities since the 1980s with a growing focus on community-driven, culturally sensitive approaches. More recent studies have focused exclusively on SSB consumption. Key SSB-related intervention elements included incentivising healthier options; reducing availability of less-healthy options; nutrition education; multifaceted or policy implementation (store nutrition or government policy).

CONCLUSIONS

There was a relatively large number of studies reporting data on SSB consumption and/or sales, predominantly from remote and rural settings. During analysis it was subjectively clear that the more impactful studies were those which were community driven or involved extensive community consultation and collaboration. Extracting additional SSB-specific consumption data from an existing nationally representative survey of Aboriginal and Torres Strait Islander people could provide detailed information for demographic subgroups and benchmarks for future interventions. It is recommended that a consistent, culturally appropriate, set of consumption measures be developed.

Testing the Price of Healthy and Current Diets in Remote Aboriginal Communities to Improve Food Security: Development of the Aboriginal and Torres Strait Islander Healthy Diets ASAP (Australian Standardised Affordability and Pricing) Methods

Aboriginal and Torres Strait Islander peoples suffer higher rates of food insecurity and diet-related disease than other Australians. However, assessment of food insecurity in specific population groups is sub-optimal, as in many developed countries. This study tailors the Healthy Diets ASAP (Australian Standardised Affordability and Pricing) methods protocol to be more relevant to Indigenous groups in assessing one important component of food security. The resultant Aboriginal and Torres Strait Islander Healthy Diets ASAP methods were used to assess the price, price differential, and affordability of healthy (recommended) and current (unhealthy) diets in five remote Aboriginal communities. The results show that the tailored approach is more sensitive than the original protocol in revealing the high degree of food insecurity in these communities, where the current diet costs nearly 50% of disposable household income compared to the international benchmark of 30%. Sixty-two percent of the current food budget appears to be spent on discretionary foods and drinks. Aided by community store pricing policies, healthy (recommended) diets are around 20% more affordable than current diets in these communities, but at 38.7% of disposable household income still unaffordable for most households. Further studies in urban communities, and on other socioeconomic, political and commercial determinants of food security in Aboriginal and Torres Strait Islander communities appear warranted. The development of the tailored method provides an example of how national tools can be adapted to better inform policy actions to improve food security and help reduce rates of diet-related chronic disease more equitably in developed countries.

Buchanania obovata: An Australian Indigenous food for diet diversification

AIM

Buchanania obovata Engl., the Green Plum, is a small green fruit eaten by Australian Indigenous peoples of the Northern Territory and Western Australia that has had limited study and has potential as a source of food for diet diversification. The flesh and seed of the fruit are eaten and the plant is used as bush medicine.

METHODS

Physical characteristics of the fruit were measured. The flesh and seed freeze dried powders were measured separately for proximates, mineral/trace elements and heavy metals, and folate analysis. Vitamin C was analysed in the flesh.

RESULTS

The flesh is high in protein (12.8 g/100 g dry weight (DW)) and both flesh and seed are high in dietary fibre (55.1 and 87.7 g/100 g DW, respectively). The flesh is high in potassium (2274.7 mg/100 g DW), and is a good source of magnesium (570.5 mg/100 g DW), calcium (426.0 mg/100 g DW) and phosphorous (216.8 mg/100 g DW), whereas the seed is high in iron (8.15 mg/100 g DW). The flesh contains folate at 752.4 μg/100 g DW and the seed contains 109.5 μg/100 g DW as pteroylmonoglutamic acid equivalents.

CONCLUSIONS

The flesh and seed have good nutritional properties and the results support the use of the Green Plum for diet diversification and nutrition in Indigenous and non-Indigenous populations in Australia.

The burden and nature of malnutrition among patients in regional hospital settings: A cross-sectional survey

BACKGROUND/AIMS

Indigenous people experience a higher burden of nutrition-related conditions and are more likely to experience food insecurity compared to non-Indigenous people. Consequently, they remain at increased risk of malnutrition; particularly when residing in regional or remote areas. This study aims to compare and characterise the burden and nature of malnutrition among a representative cohort of Indigenous and non-Indigenous Australians admitted to regional hospitals for medical inpatient care.

METHODS

This was a cross-sectional survey conducted in three regional hospitals in the Northern Territory and Far North Queensland of Australia from February 2015 to September 2015. A total of 1606 adult medical inpatients were screened for eligibility. Of these, 608 eligible patients were screened for malnutrition using the validated Malnutrition Screening Tool and assessed for malnutrition using the Subjective Global Assessment. Socio-economic and health-related variables and anthropometric measurements were collected to identify the correlates of malnutrition.

RESULTS

Of the 271 Indigenous patients and 337 non-Indigenous patients screened and assessed for malnutrition, 250/608 (41.7%, 95% CI 40.1-52.3%) were found to be malnourished. Significantly higher rates of malnutrition (46.1%, 95% CI 40.1-52.3% versus 37.1%, 95% CI 31.9-42.5%) were found in Indigenous patients compared to non-Indigenous patients (P = 0.024). Higher rates of malnutrition were observed in Indigenous patients residing in Central Australia (56.7%, 95% CI 46.7-66.4%) than in the Top End of the Northern Territory (40.7%, 95% CI 31.7-50.1%) and in Far North Queensland (36.7%, 95% CI 23.4-51.7%). Factors independently predictive of malnutrition for both Indigenous and non-Indigenous participants included residence in Central Australia (OR 4.31, 95% CI 2.63-7.90, P < 0.001); an increased Charlson Comorbidity Index prognostic score (OR 1.37 [per incremental score], 95% CI 1.19-1.59, P < 0.001); and an underweight Body Mass Index (OR 29.97, 95% CI 3.68-244.0, P < 0.001). Of the 250/608 patients who were malnourished, the positive predictor value (PPV) for malnourished patients who were underweight was 96.6% (95% CI 88.3-99.6%); for Indigenous Australians who were malnourished and underweight, the PPV was 100%. A mid-upper arm circumference of less than 23 cm demonstrated a strong PPV for all patients who were malnourished (96.1%, 95% CI 89.0-99.2%).

CONCLUSION

This is the first study to characterise malnutrition in adult Indigenous Australians in a hospital inpatient setting. Compared to non-Indigenous patients the burden and pattern of malnutrition was both higher and markedly different among Indigenous patients. These data highlight the critical importance for actively screening for and responding to malnutrition in this vulnerable patient population in regional and remote settings.

What do we know about the diets of Aboriginal and Torres Strait Islander peoples in Australia? A systematic literature review

OBJECTIVE

To provide an overview of published research on the dietary intake of Aboriginal and Torres Strait Islander peoples.

METHODS

Peer-reviewed literature from 1990 to October 2016 was searched to identify studies that measured the dietary intake of Australian Aboriginal and Torres Strait Islander populations. Study quality was assessed using a purposely devised quality appraisal tool. Meta-analysis was not possible due to the heterogeneity in dietary intake assessment methods. A narrative synthesis of study findings, where key themes were compared and contrasted was completed.

RESULTS

Twenty-five articles from twenty studies with outcome measures related to dietary intake were included. Dietary intake was assessed by electronic store sales, store turnover method, 24-hour dietary recall, food frequency questionnaire and short questions. Consistent findings were low reported intakes of fruit and vegetables and high intakes of total sugar and energy-dense, nutrient-poor food and beverages.

CONCLUSIONS

While differences between studies and study quality limit the generalisability of the findings, most studies suggest that the diets of Aboriginal and Torres Strait Islander peoples are inadequate. Implications for public health: A more concerted approach to understanding dietary patterns of Aboriginal and Torres Strait Islander peoples is required to inform policy and practice to improve diet and nutrition.

Feasibility of a novel participatory multi-sector continuous improvement approach to enhance food security in remote Indigenous Australian communities

Background

Food insecurity underlies and compounds many of the development issues faced by remote Indigenous communities in Australia. Multi-sector approaches offer promise to improve food security. We assessed the feasibility of a novel multi-sector approach to enhance community food security in remote Indigenous Australia.

Method

A longitudinal comparative multi-site case study, the Good Food Systems Good Food for All Project, was conducted (2009–2013) with four Aboriginal communities. Continuous improvement meetings were held in each community. Data from project documents and store sales were used to assess feasibility according to engagement, uptake and sustainability of action, and impact on community diet, as well as identifying conditions facilitating or hindering these.

Results

Engagement was established where: the community perceived a need for the approach; where trust was developed between the community and facilitators; where there was community stability; and where flexibility was applied in the timing of meetings. The approach enabled stakeholders in each community to collectively appraise the community food system and plan action. Actions that could be directly implemented within available resources resulted from developing collaborative capacity. Actions requiring advocacy, multi-sectoral involvement, commitment or further resources were less frequently used. Positive shifts in community diet were associated with key areas where actions were implemented.

Conclusion

A multi-sector participatory approach seeking continuous improvement engaged committed Aboriginal and non-Aboriginal stakeholders and was shown to have potential to shift community diet. Provision of clear mechanisms to link this approach with higher level policy and decision-making structures, clarity of roles and responsibilities, and processes to prioritise and communicate actions across sectors should further strengthen capacity for food security improvement. Integrating this approach enabling local decision-making into community governance structures with adequate resourcing is an imperative.

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A diverse group of stakeholders engaged in a continuous improvement process of community-led action to strengthen food security.

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Stakeholders collectively appraised the whole local food system and prioritised strategies to improve food security.

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Actions able to be directly implemented within available resources resulted from developing collaborative capacity.

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Positive shifts in community diet were associated with key areas where actions were implemented.

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Integrating the approach with higher level decision-making structures could further strengthen capacity for food system improvement.

Costing ‘healthy’ food baskets in Australia – a systematic review of food price and affordability monitoring tools, protocols and methods

Objective

To undertake a systematic review to determine similarities and differences in metrics and results between recently and/or currently used tools, protocols and methods for monitoring Australian healthy food prices and affordability.

Design

Electronic databases of peer-reviewed literature and online grey literature were systematically searched using the PRISMA approach for articles and reports relating to healthy food and diet price assessment tools, protocols, methods and results that utilised retail pricing.

Setting

National, state, regional and local areas of Australia from 1995 to 2015.

Subjects

Assessment tools, protocols and methods to measure the price of ‘healthy’ foods and diets.

Results

The search identified fifty-nine discrete surveys of ‘healthy’ food pricing incorporating six major food pricing tools (those used in multiple areas and time periods) and five minor food pricing tools (those used in a single survey area or time period). Analysis demonstrated methodological differences regarding: included foods; reference households; use of availability and/or quality measures; household income sources; store sampling methods; data collection protocols; analysis methods; and results.

Conclusions

‘Healthy’ food price assessment methods used in Australia lack comparability across all metrics and most do not fully align with a ‘healthy’ diet as recommended by the current Australian Dietary Guidelines. None have been applied nationally. Assessment of the price, price differential and affordability of healthy (recommended) and current (unhealthy) diets would provide more robust and meaningful data to inform health and fiscal policy in Australia. The INFORMAS ‘optimal’ approach provides a potential framework for development of these methods.

Testing the price and affordability of healthy and current (unhealthy) diets and the potential impacts of policy change in Australia

BACKGROUND

Price and affordability of foods are important determinants of health. Targeted food pricing policies may help improve population diets. However, methods producing comparable data to inform relevant policy decisions are lacking in Australia and globally. The objective was to develop and pilot standardised methods to assess the price, relative price and affordability of healthy (recommended) and current (unhealthy) diets and test impacts of a potential policy change.

METHODS

Methods followed the optimal approach proposed by INFORMAS using recent Australian dietary intake data and guidelines. Draft healthy and current (unhealthy) diet baskets were developed for five household structures. Food prices were collected in stores in a high and low SES location in Brisbane, Australia. Diet prices were calculated and compared with household incomes, and with potential changes to the Australian Taxation System. Wilcoxen-signed rank tests were used to compare differences in price.

RESULTS

The draft tools and protocols were deemed acceptable at household level, but methods could be refined. All households spend more on current (unhealthy) diets than required to purchase healthy (recommended) diets, with the majority (53-64 %) of the food budget being spent on 'discretionary' choices, including take-away foods and alcohol. A healthy diet presently costs between 20-31 % of disposable income of low income households, but would become unaffordable for these families under proposed changes to expand the GST to apply to all foods in Australia.

CONCLUSIONS

Results confirmed that diet pricing methods providing meaningful, comparable data to inform potential fiscal and health policy actions can be developed, but draft tools should be refined. Results suggest that healthy diets can be more affordable than current (unhealthy) diets in Australia, but other factors may be as important as price in determining food choices.