1. The economics of food choice in remote Indigenous communities Kerin O’Dea Sansom Institute for Health Research University of South Australia

2. Consistent pattern of food intake over many decades Very high intakes of refined carbohydrates, soft drinks, fatty meats Very low intakes of fresh fruits and vegetables and lean meats and fish

3. Why have these patterns persisted for over 20 years? Ignorance or poverty?? Widely held assumption that food preferences are conservative: “flour, sugar, tea” Our observations are very different – People appreciate high quality food – Keen to taste new dishes – Understand quite well the qualities of healthy western foods Julie Brimblecombe, PhD thesis, 2007

4. Interventions to improve diet quality in remote community stores The Minjilang Project: Amanda Lee et al, 20 years ago Looma Healthy Lifestyle:15 years ago – Both interventions showed that the quality of the food supply could be improved Increased consumption of fresh fruit and vegetables Reductions in fat and sugar – This translated into reduction in CVD risk factors BUT the dietary quality changes were still below ideal

5. The economics of food choice Maximising calories Reducing food spending by changing quality before reducing quantity Over eating when food is available Women restricting their own intake to protect children Drewnowski and Darmon, AJCN, 2005

6. Fats and oils Sugar flour Fresh fruit, vegetables Lean meat, fish Energy density MJ/kg $ per MJ Confectionary Poverty and the food supply Drewnowski and Darmon, AJCN, 2005

7. Cost of dietary improvement Food itemActual quantity (g) per capita per day Modelled quantity (g) per capita per day Fruit41245 Vegetables76285 Milk powder3050 Wholegrain bread921 Table sugar9648 Aerated added sugar drinks248132 Water13130 Canned corned beef158 Hot chips2512 Pies157 Salt10.3 x 5.9 x 3.8 x 1.7 x 2.4 Additional Expenditure – at least $200 per fortnight for a family of 6 Brimblecombe, PhD Thesis Med J Aust, May 2009

8. Improving nutrition at Looma School canteen An integrated program of improved diet, health education, regular exercise – Food supply first lunch, then breakfast – Sport – Health education in curriculum Diet Exercise Smoking Alcohol and other drugs

9. Nutrient intakes provided by breakfast plus lunch, 1996 vs 1998 Intake (proportion of RDI)

10. Impact of healthy breakfast and lunch at the Looma School These two meals provided the Recommended Daily Intake for most of the key nutrients (vitamins, minerals) Schools and child care centres provide an ideal setting for such interventions – Post weaning period critical Cost-effective: well-targeted Must be supported by community Should be viewed as an investment in the future health of the next generation

11. Many different types of nutrition interventions School breakfast and lunch programs abound – No control or evaluation of quality – Need simple guidelines – Should be evaluated over the long term using simple standardised data collection Impact on school attendance and performance Impact on health Food supply interventions are less common

12. Key references O'Dea K. Marked improvement in carbohydrate and lipid metabolism in diabetic Australian Aborigines after temporary reversion to traditional lifestyle. Diabetes 33:596-603, 1984. Lee AJ, O'Dea, K, Mathews JD. Apparent dietary intake in remote Aboriginal communities. Aust J Publ Health 18: 190-197, 1994. Lee AJ, Bailey APV, Yarmirr D, O'Dea K, Mathews JD. Survival tucker: improved diet and health indicators in an Aboriginal community. Aust J Publ Health 18: 277-285, 1994. Rowley KG, Su Q, Cincotta M, Skinner M, Skinner K, Pindan B, White GA, O’Dea K. Improvements in circulating cholesterol, antioxidants, and homocysteine after dietary intervention in an Australian Aboriginal community. Am J Clin Nutr 74:442-8, 2001. Brimblecombe J, O’Dea K. Role of energy cost in food choices for an Aboriginal community in Northern Australia. Med J Aust 190:549-551, 2009.