Poor food and nutrient intake among Indigenous and non-Indigenous rural Australian children

Indigenous peoples internationally suffer greater early mortality rates and poorer health status when compared with non-Indigenous peoples [1]. In Australia this gap is greater than for any other similar country, and particularly so for chronic diseases [1‐3]. Rates of diabetes for Indigenous peoples are at least 3 times that of non-Indigenous Australians [3], and are especially high for Indigenous youth (6 times higher than for non-Indigenous youth) [4, 5]. Poor nutritional status both in utero and during childhood is recognised as a key risk factor for the development of type 2 diabetes [2], and improving the diet of children is an acknowledged strategy for reducing the risk of chronic diseases during childhood and in adulthood [6].

Similar to that of Indigenous populations internationally [7], dispossession of Australia's Indigenous peoples has contributed to endemic disadvantage [3, 8] and poor nutrition [3, 9]. This is associated with the change of dietary patterns that occurred with European invasion, from consumption of traditional nutrient dense, low energy foods [2] to a dependence on poorer quality food handouts of staples such as white flour, sugar and rice [2]. Since then food intake for Indigenous peoples has been further compounded by many factors [8] including inadequate food access and availability [3, 10], food insecurity [11] and financial stress [12], the last identified as a substantial barrier to a healthy diet [13, 14].

It is acknowledged that good quality health data from Indigenous populations internationally are limited [8] and this is also true for Australia's Indigenous peoples [7, 15], and for children and youth in particular [15, 16]. Whilst the poorer nutritional status of Indigenous peoples relative to non-Indigenous peoples has been documented [5, 7], internationally and nationally there are few studies comprehensively examining their food and nutrient intake [7, 17], and even fewer involving children [2, 7]. This represents a critical gap in the knowledge base required to develop effective health management strategies for this at-risk population [18].

The purpose of this study is to describe the food and nutrient intake of a population of Australian Indigenous and non-Indigenous rural children aged 10 to 12 years old, and who live in regions of relative social disadvantage, by examining 1) their mean daily intake of micro- and macro-nutrients and the percent contribution of macronutrients to energy; 2) the proportion of children with mean daily intakes of selected nutrients less than the estimated average requirement (EAR) or greater than the Upper Level (UL) of intake, as appropriate, and 3) the main food groups and sub-groups contributing to energy, fat, saturated fat, sugar, sodium and fibre.

Indigenous communities who participated in this research prefer the term 'Aboriginal and Torres Strait Islander'. This term is used from here on.

All 11 schools approached agreed to participate, yielding a total of 219 Aboriginal and Torres Strait Islander and 562 non-Indigenous children. The final study population comprised 259 children, a response rate of 47% (n = 102) of Aboriginal and Torres Strait Islander children and 28% (n = 157) of non-Indigenous children. Of these, 256 children completed at least one 24-hour recall, and 215 children completed three 24-hour recalls each (including one weekend day) and were included in the analysis (Refer to Figure 1).

This study is one of very few internationally to comprehensively examine the food and nutrient intake of either Indigenous children or of children from disadvantaged rural regions generally. Aboriginal and Torres Strait Islander boys in this cohort demonstrate a statistically significantly higher intake of energy, most macro-nutrients and sodium when compared with non-Indigenous boys, a magnitude of difference not apparent in girls. The saturated fat mean percent contribution to energy is high for all children at about 5% above the Australian recommended range [29] and about 1.6% above the contributions found in other recent studies of children and adolescents [26, 30, 31], with intakes significantly higher for Aboriginal and Torres Strait Islander children than for their non-Indigenous counterparts. More than 70% of children consumed less than the EAR for fibre and calcium (at age 12-13 years) with these proportions being greater than for national data [26]. Seventy percent and higher consumed more than the UL for sodium and mean intake was similar to national data for Aboriginal and Torres Strait Islander boys (2934.5 mg) and all girls (2334.5 mg). The proportions of girls not meeting EAR for folate and magnesium, is three times that of the national population [26]. These results are consistent with international studies of children from low socio-economic regions [32‐34]. There is an association between poor dietary intake of these nutrients and the development of cancer, cardiovascular disease, type 2 diabetes, other chronic diseases and neural tube defects [31, 35‐38], all of which occur at higher rates in Aboriginal and Torres Strait Islander communities [2, 3].

Intakes of EDNP foods are excessive for all children, with contributions to daily energy intake substantially greater than Australian recommendations (14-17%) [39] for children aged 2 to 18 years [40], and than those of the only recent national study of EDNP food intake for children aged 9 to 13 years (38%) [41]. Some caution needs to be exercised when comparing results across studies as definitions of EDNP foods vary [42].

Compared with national data at 9-13 years of age [26] mean daily energy intake in this study is slightly lower for boys overall at 8885.3 kJ compared with 9645.8 kJ, however is similar for Aboriginal and Torres Strait Islander boys (9689.8 kJ). Girls mean energy intake is comparable at 8176.4 kJ overall compared with 8166.6 kJ in the national study. Difference may be due to different methods, with the data for the national study being obtained from two 24 hour recall compared with the three administered in this study.

White bread is the highest ranked food item in the top food category (bread) contributing to energy. Although bread is a 'core food'[40]. more nutrient-dense versions of this very common food item would be preferable [43] given the study population's poor dietary profile and the consequent proportions of children not meeting NRVs for many nutrients.

Higher intakes of EDNP and poorer choice foods, energy, carbohydrate, total fat and saturated fatty acids amongst Aboriginal and Torres Strait Islander boys in particular, and lower intakes of fruit and vegetables amongst Aboriginal and Torres Strait Islander girls compared with their non-Indigenous counterparts is apparent and of clinical importance. These findings are similar to international studies [44‐48]. The significantly higher macro-nutrient intake of Aboriginal and Torres Strait Islander boys compared with non-Indigenous boys in our study appears to be driven by their higher consumption levels of EDNP and poorer choice foods. Aboriginal and Torres Strait Islander children who participated in this study have been shown to have a tendency to be more active than their non-Indigenous counterparts, with boys more active than girls [23]. This is likely to result in higher energy requirements and the purchase of EDNP or poorer choice foods is an affordable option to satisfy children's hunger in financially stressed communities [13, 14].

Aboriginal and Torres Strait Islander children demonstrate a greater mean daily per capita intake compared with national data in the following food categories: soft/sports drinks/cordials (457 g [boys] and 431 g [girls] - compared with 364.7 g); potato crisps/salty snacks (22 g [boys] and 17 g [girls] compared with 12.9 g); and hot chips (58 g [boys] and 38 [girls] compared with 29.3 g) [41], with these differences not apparent among non-Indigenous children. The high contribution of the latter two foods to energy for Aboriginal and Torres Strait Islander children is about twice that for national data, [41] and for hot chips this difference is similar to findings from a Canadian study [45]. The greater daily per capita intake and percent contribution to energy of soft/sports drinks/cordials by Aboriginal and Torres Strait Islander children compared with national data (about 6.7% compared with 5.4%) [41] is probably an underestimate of difference as, unlike the national data, we were unable to include 'fruit drink' (as different from 'fruit juice') in our calculations of sugary drinks. The higher consumption levels among Aboriginal and Torres Strait Islander children (about 1 4/5 cups/day) compared with non-Indigenous children (about 1 to 1 1/5 cups/day) shown in this study are concerning. This is particularly so given the significant association between high intakes (1 to 2 cups/day) of sugary drinks and the development of metabolic syndrome and Type 2 diabetes in adults [49], both of which occur at much higher rates in Australian Aboriginal and Torres Strait Islander than non-Indigenous communities [3]. The lower consumption levels of sweet biscuits/cakes/muffins by Aboriginal and Torres Strait Islander children may be due to differences in disposable income and/or preference.

Fruit and vegetable (mostly mashed potato) intake is low for all children compared with a national survey [26] and appears lower for Aboriginal and Torres Strait Islander girls than for their non-Indigenous counterparts. Overall these findings align with those from national and state reports [50, 51].

There are many factors which may impact on the poor dietary profile of children in this study including: convincing evidence that families under financial stress are unable to afford healthy foods [13, 14], and that numerous environmental attributes (for example higher proportion of 'fast food' outlets in disadvantaged areas) create a more risky environment for low socio-economic families [52]. These factors have been reported by community focus groups conducted as part of our broader program of research [11].

In the context of the poorer health status and higher levels of disadvantage experienced by Aboriginal and Torres Strait Islander communities in Australia, the differences in key food and nutrient intake found in this study are important to note and warrant further investigation. A selection bias may exist in this study with relatively low and differential participation rates, the latter possibly a result of the support provided to Aboriginal and Torres Strait Islander communities by AHWs in the recruitment stage. The low participation rate of non-Indigenous children may reflect a bias towards families with better health habits, thereby leading to a falsely high difference between Aboriginal and Torres Strait Islander and non-Indigenous children. Never the less, both groups fare poorly compared with Australian NRV's, suggesting that the poor nutrient intakes documented in this study are likely understated, ie biased towards the null. The sample size limits power to detect differences when comparing proportions meeting NRVs. There is also the possibility of a differential Hawthorne effect, with Aboriginal and Torres Strait Islander children potentially over- or under-reporting due to involvement of their local communities and AHWs. However, we believe that the involvement of the Aboriginal and Torres Strait Islander community addressed a pre-existing inequity where Aboriginal and Torres Strait Islander children, due to a lack of appropriate cultural support, may have under-reported in other dietary assessments devised and supervised by the dominant culture, and been reluctant to participate in studies.

The 24-hour recall method relies on child self-report which has been shown to be as reliable as parental report by age 10 years, although there may be some difficulties in quantifying portion size at this age [53]. Recall may be influenced by the retention interval, interview format, prompts used, and correlates such as gender, BMI, and age [54]. To mitigate against this we have used the mean of 3 24-hour recalls, thus providing more robust data from this method, which may be more appropriate to use cross-culturally and with low-income participants [55] as well as with those who may be cautious about engaging in a study or for whom literacy is an issue [56]. Data were collected from children in three coastal areas and in one season during the year, and this may limit the generalisability of the findings. In addition, at the time of data entry, the latest version of the AusNut (2007) was not available, and so we used the older (1999) version, with some additions for the two key nutrients known to have changed in the food supply. However, it is possible that some other nutrients also changed in that period, and this may further limit comparisons to nutrient data provided by more recent surveys, such as the 2007 Children's Survey. However, the comparisons by foods and food groups are still possible, without concern for this potential limitation.

All rural children in this disadvantaged population showed high intake levels of energy-dense and/or nutrient-poor foods and substantial proportions consumed less than EAR for important nutrients. Targeted intervention strategies need to be developed to address rural children's high consumption of white bread, processed meats, hot chips, soft drink and salty snacks, as well as these foods ready availability. Differences in intake by Indigenous status need further investigation particularly for Aboriginal and Torres Strait Islander boys, as do differences in nutrient intake and contributions of EDNP foods to key nutrients in the context of disadvantage, financial stress, and current health status experienced by Australia's Indigenous people. These findings are cause for concern for the wellbeing of Aboriginal and Torres Strait Islander children, who will continue to be at a higher risk than their non-Indigenous counterparts of developing chronic diseases such as diabetes as they become older.