In 2008 the Australian government released its Closing the Gap Strategy, which laid out plans to achieve health equality for Aboriginal and Torres Strait Islander people by 2030.
How is it tracking?
Not well, according to a 10-year review by the Australian Human Rights Commission – if anything, the gap has grown.
Of all Australian population groups, Aboriginal and Torres Strait Islander people still suffer the worst health outcomes, and their lives are about 10 years shorter than the rest of the populace.
According to Robert Tickner from the Australian Red Cross, “It is a national disgrace that, despite our reputation as one of the world’s most bountiful food producers, so many Australians cannot get adequate, nutritious and affordable food.”
Poor nutrition is a key contributor to the overburden of health issues faced by Indigenous Australians, which include overweight and obesity, malnutrition, heart disease, type 2 diabetes, chronic kidney disease and tooth decay.
These diseases contribute to at least three-quarters of their mortality gap.
Food insecurity is a big part of the problem. Much of this is due to poverty. Many Indigenous Australians also live in remote communities where healthy food is hard to come by. What is available is expensive because of transport costs.
As a result, fresh fruit and vegetable intake is very low, and “discretionary foods” make up 41 percent of their daily energy intake. Sugar consumption – largely from sweetened drinks – is nearly 50 percent more than the World Health Organisation’s recommendations.
Combined with easy access to unhealthy food and drinks, poor education and nutrition literacy is also part of the problem.
Many community-based programs have helped, the most successful being those with multi-level strategies that encourage community involvement at every stage of their development and implementation to make sure they are culturally appropriate and address local needs.
Some programs have focussed on improving the food supply through local retail outlets, school and community gardens, food provision by community organisations, and community store nutrition policies.
Nutrition education can also help, if delivered in conjunction with making healthy food accessible through cooking education, budgeting advice, and group-based lifestyle programs.
But these are band aid solutions to the overarching problem: there have been no nationally coordinated nutrition ventures since the National Aboriginal and Torres Strait Islander nutrition strategy and action plan expired in 2010.
The situation can be traced to many historical factors; indeed, all the evidence suggests that before European settlement Indigenous Australians enjoyed good health and a varied diet of nutritious fresh plant and animal foods.
Now they suffer socioeconomic disadvantage with low income and unemployment, institutional racism, low access to primary health care and poor quality, overcrowded housing, all of which contribute to ill-health and mortality.
Health equality is a basic human right. Treating diseases and improving nutrition and food security are important, but the review argues that underlying structural factors also need to be tackled before Australia can close the gap.
One in three hospitalised adults in the US is at risk for malnutrition, a major analysis has found. And patients’ poor food intake is having a significant impact on their healing and recovery, compounding their risk of death.
“Nutrition is easily overlooked as healthcare professionals often focus on a patient’s primary diagnosis,” lead author Abby Sauer told NutritionInsight.
“It may come as a surprise to some that when patients don’t get proper nutrition, it can significantly put their health and lives at risk,” she adds, explaining that nutrition is more important than ever when someone is sick or injured.
The researchers screened around 10,000 patients from 2009 to 2015 to assess malnutrition risk and links with mortality.
They found around one in two patients were eating half or less of their meals. This low food intake was linked to higher risk of mortality, and those who ate none of their food had a nearly six-fold higher risk of dying than those who ate at least some.
The findings support previous studies that have identified hospital malnutrition as a global public health problem, including Australian research which also found that this “silent epidemic” affects one in three hospitalised patients.
Despite this growing awareness, it is still not given the attention it deserves.
“Malnutrition can be invisible to the eye and is rampant in US hospitals because it’s not always top of mind,” said Gail Gerwitz, president of nutritionDay, an organisation which was involved in the study.
Loss of muscle mass and strength takes the brunt of poor nutrition, leading to sarcopenia, an age-related disease of accelerated muscle wasting that results in a downward spiral of poor health and mortality.
Some Australian hospitals are taking action by implementing basic malnutrition and sarcopenia screening tools. Relatives can also look for key signs of malnutrition.
These include unexpected weight loss, tiredness, low mood, poor appetite, unhealthy teeth and gums, listless hair and brittle nails, constipation and poor wound healing.
Hospitals and aged care facilities can take several measures to boost patients’ food intake, by using patient-centred service models, introducing mandatory nutrition standards, addressing obstacles to eating like poor dentition, and providing a choice of meals that are tasty and appealing.
High protein, high energy meals are the first line of defence to prevent or address malnutrition and promote healing. This can be achieved by adding extra cream or butter to food. Where necessary – especially with poor appetite – supplements can be used between meals to boost protein and calorie intake.
Many older adults don’t eat enough to meet their nutritional needs, and this can impact their healing and recovery from injury.
In support of this, a 2-year pilot study has shown that giving one extra meal a day to older adults who were hospitalised with hip fractures halved their risk of dying.
The study, conducted by the NHS in the UK, was instigated after staff noticed that patients with hip fractures struggled to get enough nutrients. In the program, nutrition advisors across six sites brought food from the hospital’s canteen and sat with patients as they ate their extra meal.
As a result, mortality rates fell from 11 to 5.5 percent, and medical authorities are considering whether it should be introduced countrywide.
Often, busy staff overlook patients’ food intake, noted chief orthopaedic surgeon Dominic Inman. Commenting on the findings to The Telegraph, he said, “If you look upon food as a very, very cheap drug, that’s extremely powerful.”
Hip fractures are the most common, and most serious type of fracture in Australia, with new fractures resulting in 50,900 hospitalisations and 579,000 bed days throughout 2015-16.
The health of adults over 50 often rapidly declines after a hip fracture, exacerbating poor outcomes. For three months after fracturing a hip, older adults are at five to eight times greater risk of dying, and one in three adults over 50 dies within 12 months.
Aside from that, a hip fracture can sorely impact mobility, independence and quality of life, and many patients are transferred to another facility for ongoing care.
Falls can be prevented by maintaining good muscle mass and strength. Failing that, patient outcomes after a fall can be improved with rehabilitation aimed at getting them moving as soon as possible, and with good nutrition.
Malnutrition, although widespread, is often overlooked, so it is important to be aware of the signs.
Addressing this, Queensland researchers have tested a patient-centred food service model in a public hospital setting and showed that it increased patients’ energy and protein intake – key requirements for healing and preventing malnourishment.
The model has been used in private acute care settings for 15 years. It revolves around providing room service to patients on demand – so they get to choose what they eat and when. (Who wants dinner at 5pm if you’re not ready for it?)
This food revolution was led by Sally McCray, who says, “This innovate model demonstrates the importance of patients being able to order flexibly, both in terms of the type of food items that patients feel like eating, as well as ordering food at a time of day that they feel like eating.”
The researchers showed that, not only can it improve nutrition intake, it also results in happier patients and reduced food waste.
To dig deeper into menu planning, we spoke with Dr Karen Murphy, accredited practising dietitian and senior research fellow at the University of South Australia.
Karen: Many things need to be considered in menu planning for aged care. Firstly, are they in high level care or independent living facilities?
Dining facilities are important. Older adults are at risk of malnutrition because their energy needs drop and so does their appetite. We know that social dining increases food intake, and it’s important to consider the taste and flavour of foods.
Available cutlery and ability to eat the food. Can everyone use a knife and fork or are sporks better? People with arthritis and reduced mobility in their hands may need cutlery with curved handles.
Can meals and snacks be prepared on-site or does food need to be bought externally and brought in? Consider budgetary restraints.
Medical requirements: dysphagia requires different textures to avoid choking; chewing difficulties with dentition; loss of interest/depression; physical immobility.
Vegetarian options should be available. Some may need foods with higher protein and fat content to avoid malnutrition.
Karen: Menu fatigue means getting sick of the same food. It can often be a problem in hospitals or aged care facilities where menus are rotated fortnightly or monthly and can get very boring. This impacts food intake.
Sometimes there are budgetary constraints on menu development, kitchen facilities for preparing large amounts of food, or the types of food that can be produced and kept at temperature.
Karen: Get them involved. Ask them what can I/we do to make it easier for you? What do they like to eat? What can they prepare? Do they prefer smaller regular meals rather than big meals? Can they handle the food packaging?
Families can help in several ways. For instance, re-packaging foods if they are hard to open, or helping with bulk preparation of favourite meals and storing them as individual serves.
Karen: If they are at risk for malnutrition, needing high energy high protein foods, suggest prioritising food to meet the protein RDI.
Some ideas: milk drink or Sustagen, smooth peanut butter and banana or ricotta cheese and avocado on crumpets, cheese and crackers, hardboiled egg or omelette, full fat yoghurt, savoury cheese muffins, nuts (if chewing/swallowing isn’t a problem), dried fruit, baked beans, nutritious dips, mini puddings, pikelets with jam and cream.
Karen: Meals should focus on high nutrient density, soft textures, fibre and flavour. Milk powder and olive oil can be added for extra protein and calories if needed. Some examples:
Karen: Attention is being given to increasing the social side of dining, improving the whole dining experience. Menus are becoming more creative; texture modified foods are advancing to make them tastier and more visually appealing.
The increase in reality cooking shows is drawing attention to the appearance of food to make it more appetising. The nutritional content of meals and using healthy fats like extra virgin olive oil I think will creep into menu planning, and using external meal services might receive more attention.
We would like to thank Dr Karen Murphy for her time.