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Obesity in Australia

CHAIR —Welcome, Dr Jeffries-Stokes. Although the committee does not require you to speak under oath, you should understand that these hearings are formal proceedings of the Commonwealth parliament. Giving false or misleading evidence is a serious matter and may be regarded as a contempt of parliament. On that note, I will ask you to make a brief introductory statement before we proceed to questions.

Dr Jeffries-Stokes —My particular interest is in Aboriginal health. I am a paediatrician in the Goldfields. I first went to the Goldfields in 1991, when I was working with the Institute for Child Health Research, to help set up and evaluate a maternal and infant health service for Aboriginal women in the region. During that project, I met my husband, who is a senior man of the Wongatha tribe. I married him and became part of the Aboriginal community in the Goldfields.

Since 1994, I have been a paediatrician in the Goldfields, and for a lot of that time the only paediatrician basically between Perth and Alice Springs. I have a particular interest in diabetes and kidney disease, because it is a major factor in the very high death rate and morbidity rate of Aboriginal people, particularly in the Goldfields and the Central and Western Deserts.

The development of the Western Desert Kidney Health Project started really with discussions after funerals. We attend lots of funerals in the Goldfields, and we have family and extended family asking, ‘What is this? Why are our people dying?’ My sister-in-law Annette Stokes, who is a fantastic Aboriginal researcher, and I said, ‘Well, it’s preventable,’ and they said, ‘If you know that, why aren’t you doing something about it?’

So out of that grew the Western Desert Kidney Health Project, which began in 2007 with a pilot study in Leonora, Laverton and Mount Margaret, and I brought some copies of that report for you. It took several years of consultation and talking about how to do this and what to do, and we then went to Leonora, Laverton and Mount Margaret. We started off with a diet survey. We surveyed about 55 people, mostly Aboriginal people, about their dietary habits—what they were eating and what they would like to eat if they could. We also brought in a team of gardeners, who taught permaculture gardening.

Over the 12 months more than 600 people were screened for the risk factors for kidney disease and diabetes, and we found that over 54 per cent of people—and they were predominantly Aboriginal people, adults and children—were obese, with a BMI of over 25, and 20 per cent had a BMI of over 35, so very obese, the heaviest being about 155 kilos. We also found a very high prevalence of acanthosis nigricans, which is darkening around the neck, under the arms and in areas of friction and is an indication of high insulin levels, and, as you would expect, high rates of diabetes and kidney disease. In fact, we found that three per cent of the 600 people—so 20 people—were actually in renal failure and were not aware of it at the time.

Then we presented the intervention, which the book that you have is about, where we brought in a team of artists to work with the community to educate them particularly about the causes for hyperinsulinism, which is the underlying factor in obesity, diabetes and kidney disease, particularly in the Aboriginal population. They worked with the community for six weeks, developing their own health promotion materials that were specific for their communities, in appropriate language, but also the process of doing that meant that people learnt the messages, internalised them and were then able to teach them to their own families and their communities.

We rescreened everyone after 12 months. There was quite a lot of movement, so only about a third of people were seen at the beginning and at the end, because people come and go a lot, but overall we found that, of the people that were seen 12 months apart, 26 per cent lost weight, 25 per cent of those with a BMI over 25 improved their BMI quite significantly and 32 per cent lowered their cholesterol from the high range into the normal range. These are preliminary results—they are raw results—because I have not finished analysing the data. I thought with the cholesterol result that the machine must have been wrong and must not have been calibrated properly, but in fact it was calibrated properly. When we asked people what happened, they said, ‘Well, we did what you said. We changed our diet, we stopped eating so much carbohydrate and went back to eating native animal meat and fruit and vegetables.’

In the dietary survey that we did, we found, significantly, that 30 per cent of the people surveyed—and they were a mix of adults and high school children—had not eaten any fruit and vegetables in the previous 24 hours. The reasons they gave for that were that it was not available, that it was too expensive, that they did not know what to do with it and that they were bored with the very limited range of fruits and vegetables available to them. Now we are working to expand that project to the whole of the Goldfields.

For me the question is not really about obesity; it is about access to a healthy diet. We found that lots of people were living on two-minute noodles and Weetbix because that is all they could afford. The very high intake of refined carbohydrates was driving the insulin production, which drives your appetite. It causes microvascular damage. If you get diabetes, you should get renal failure in 20 years, but indigenous people around the world get renal failure in a few years, and it is probably because of the very high insulin levels that have probably been present from birth.

I see babies who have profound hypoglycaemia because they have been exposed to a high sugar environment in utero, so when they are born their insulin levels are high, their blood sugar has dropped dramatically, and we have to give them high amounts of dextrose or glucose in the first 24 to 48 hours of life. I then see those children again at the age of two or three, and by the age of four they are starting to develop acanthosis nigricans. In my clinical practice, I have children as young as nine who actually have established type 2 diabetes.

The issue for me is about how to get people a better, a healthier, diet. It is not rocket science. The basic thing is getting them fruit and vegetables and decent meat, particularly getting back to eating native animal meat. There are other things about that which are important, particularly the omega-3 content. Omega-3 is very important for brain development. It is important for learning, it is important as protection against the development of metabolic syndrome and diabetes and kidney disease and it is important in mood. Australian native animals are very high in omega-3, whereas farmed animals are extremely low in omega-3.

There are lots of reasons why eating Australian native animal meat, particularly in remote communities, is a good thing, but it is becoming increasingly difficult because of the need to have a gun, which means you need to have a gun licence, a safe and a car. It has been hunted out around the settlements, so you have to be able to go a reasonable distance. There is no income to be made from it, because the meat is not butchered in an abattoir, so you cannot sell it. There are a whole range of things about that. One aspect is the meat and the quality of protein that people are getting and another aspect is fruit and vegetables. Access is extremely poor and quality is generally poor, because it has had to come a long way. If we could change things so that there was more locally produced or even more frequently available fruit and vegetables, we would see a major difference in health in general, because fruit and vegetables are not only going to protect people to some degree against obesity, they contain all sorts of vitamins and trace elements which are really important.

CHAIR —Just going back to the fresh foods and the availability, one comment you made which is really interesting is that some people say they do not know what to do with them. Isn’t having the skills also a big issue?

Dr Jeffries-Stokes —Yes, it is.

CHAIR —Is that more of an issue than availability? We know that availability is a big problem.

Dr Jeffries-Stokes —No, availability is probably the biggest issue, and not knowing what to do with the vegetables so that they are not boring. The gardening project was extremely successful. People grew all sorts of vegetables. One old lady came to me and she said, ‘It’s great. I’ve got this great garden. But what do you do with this?’ and it was a zucchini. She said, ‘It’s not a cucumber. What do you do with it?’

When my husband was a child, he lived in the bush. He grew up in the bush until 1967, before his family moved into town. They had never seen tomatoes, zucchinis, a lot of the vegetables that we take for granted, and so there was no tradition of cooking those or how to prepare them. Similarly, with all the legumes and things—they were totally new. Chickpeas and lentils and things were totally foreign. But they are very valuable sources of protein and fibre and nutrients, and they are cheap.

So as part of the project we actually brought in a chef, as you will see from some of the booklets. The projects ended with a festival in each place. We brought in a chef and he taught, particularly, how to cook vegetables and how to make interesting salads and things. It was extraordinarily successful. I was amazed. The first festival was in Leonora on the Monday night, the second one in Laverton on Wednesday and the third in Mount Margaret on Friday. After the Monday night in Leonora there were some young boys who had formed a band and performed. They were great. They had written songs about diabetes and stuff. I said to them, ‘Are you going to come to Laverton?’ They said, ‘You gonna have them salads?’ When I said, ‘Yes,’ they said, ‘Yep, we’re coming.’ From the survey, people have a great desire to try different sorts of fruits and vegetables, but they just do not have the opportunity. So learning how to cook stuff is really important.

The other thing that is really important is that most Aboriginal communities now do not get normal TV. They have only got Foxtel, so there is no public health advertising and there are no community service announcements. It is a diet of violent cartoons, boxing and wrestling predominantly, and MTV music, so they are not getting access to cooking shows, and we took cookbooks and they were snapped up. Really, people were very keen. So there is a lot of interest in it, but if you are in Laverton you cannot buy a cookbook. You are lucky if you can buy a pot. So you are stuck with what you already know, which is basically frozen peas and corn, potato, carrots and maybe salad, if you can get lettuce, but often you cannot buy any lettuce or tomatoes or anything—in the remote communities like Tjinintjarra, even more so, because if you are lucky the truck gets through once a week with deliveries of fruit and vegetables, but in most cases it is more like once a fortnight, and it is all gone in the first day.

CHAIR —Just before we go on to further questions, the committee has agreed to accept Dr Jeffries-Stokes submission as evidence.

Mr COULTON —Doctor, I have a couple of questions. The first one is a pretty basic question and I probably should know, but are tinned fruit and vegetables an adequate substitute in these places or does the processing of them make them less suitable?

Dr Jeffries-Stokes —It is variable. It is not as good as very fresh but, compared to food that has been stored for a long time and then transported, it is probably better in some cases. It certainly contains all the fibre and some of the nutrients. Some of the trace elements and vitamins may be lost in the process, but frozen and tinned stuff can be as good or better than the quality of fresh fruit and vegetables in remote areas. So, yes, it would be a start. One of the things we have been looking at is forming a link with Foodbank to get fruit and vegetables out there. Foodbank is very keen to provide them—tinned, dried, frozen or whatever—but there is the cost of getting it there and the infrastructure to do that. It is really difficult.

For example, Mount Margaret has a shop which is not operating. They have got the freezers, they have got the shelving, they have got everything, but we cannot get the food from Foodbank to them. We occasionally get some sent up through Granny Smith Mine a pallet a time, but it is not a regular supply. But with a bit of imagination and support Mount Margaret could become a Foodbank depot for the northern goldfields. People would travel there from Leonora and Laverton to get some foods, which would then supplement their diet and give them a wider variety of food and the possibility to use what money they did not spend on some foods to buy other things like meat.

Mr COULTON —The other thing is that we talk about the disadvantages of an isolated community, but what has come through—and I have seen it in my own area—is that quite often a community that is reasonably small relies on itself.

Dr Jeffries-Stokes —Yes.

Mr COULTON —Community members encourage each other. We have heard this morning from the Western Australian Department of Health about communities that have banded together and had great results, and I have seen that in my own area where a town got together and lost a tonne of weight over 12 months or something like that.

Dr Jeffries-Stokes —Yes.

Mr COULTON —How much was that community spirit behind the success of your program?

Dr Jeffries-Stokes —I think that is really important, and giving people something important to do is really important, so, yes, there was a lot of community spirit involved. That is one of the reasons that we chose the community arts method of intervention. It brought the community together. It gave people something to do. It gave people something to be proud of and to get kudos for, which provides encouragement, and—particularly for the teenagers—ways of getting positive reinforcement. So the community stuff is really important, yes.

Mr COULTON —One of the things we have been told is that people with busy lifestyles do not have time to exercise and things like that. Possibly in the more remote areas the problem is the other way: that there is not a lot to do and there is a lack of motivation generally.

Dr Jeffries-Stokes —Yes.

Mr COULTON —Did you tie in an exercise program, a young mums exercise group or an older people’s exercise group, or walking mornings or things like that?

Dr Jeffries-Stokes —We did not specifically do that, and that came out of our consultations, because a lot of Aboriginal people cannot understand why you would do that. Traditionally you did not waste energy with meaningless exercise just for exercise’s sake. Also, you have to remember it is pretty harsh out there. We lived in Mount Margaret for three months and for 10 days during February it was over 45 degrees every day. So we went more for things like dance, drumming, things that were exercise but which people did not think of as exercise. They were much more fun and we found that was much more successful. Some people did organise walking and things like that, but it is pretty harsh out there. There are wild dogs and there are snakes, so it is pretty difficult to actually do that sort of thing. But the activities like dance, drumming, yoga—gardening as well as a form of exercise—were very successful.

Mr COULTON —I have got a recipe book with at least 10 things to do with a zucchini.

Dr Jeffries-Stokes —Great!

Mr COULTON —We grew them once.

Mr BRIGGS —You are quite impressive, there is no doubt about that. You might not know this and it is just out of interest really. You were talking about native animals and that the Aboriginal people used to hunt them a lot more and so forth. Before white settlement, presumably they did not have access to zucchinis and fruit and veg like that either. Was there then the problem with diabetes?

Dr Jeffries-Stokes —No. That is very interesting. I am part of an international study group looking at Indigenous diet around the world and it challenges a lot of what the medical profession traditionally believes about diet. When my husband was a child, his people’s diet was predominantly meat and fat, but the fat is native animal fat, so it has no cholesterol, is very high in omega-3 and very good for you, similar to the native Canadian diets where over 60 per cent of the calories actually came from fat, particularly things like eulachon grease, which comes from fish. So their diet was predominantly protein and fat, with only a very small amount of vegetables. In the Goldfields and Central Desert, there were no yams, no bananas, no mangoes—nothing like that. The vegetables that are there are small and densely packed with nutrients. For instance, quandong is one of the highest in vitamin C but there is a thin—less than one-millimetre—rim of flesh around its nut.

My husband goes hunting two or three times a week, and he and his brothers and sisters would gather quandong, honey ants and bardies, or witchetty grubs, in season all the time. So a traditional diet is very high in fat and protein. They were very healthy, but when they came into town, there were all the attractions of two-minute noodles, cream cakes et cetera.

As part of my previous work setting up the maternal and infant health service, I was interviewing people—and diet was part of that process—and a lot of them said that they found they now tended to celebrate with food and they celebrated with the foods that they were deprived of in the missions as children. They were taught that for celebration you had cake, and it was extraordinarily rare, but now—we have a big family—we have a birthday nearly every week, so there are celebrations all the time and they are with food and they are with the luxury foods of cake, chips and cool drink, which are very high in carbohydrate and unhealthy fats.

We were in Disneyland last year, and I was amazed at how far they had gone. All over Disneyland there were fruit stalls, and my children were really excited by it. They had little boxes of mangoes, grapes, strawberries, with chocolate to dip them in, and vegetables with dips and stuff, with Tinkerbell, Peter Pan, Buzz Lightyear et cetera on the boxes. I noticed that the lines at these places were longer than the lines for chips. So the marketing of stuff can work just as well for fruit and vegetables as it does for junk food. In the communities, that was one of the things, with parents saying, ‘Oh, they don’t like vegetables,’ but it is all about presentation. When we made the vegetables and things into faces on the plates, then the kids would eat it. So it is also about preparation and presentation of the foods.

Ms HALL —Thank you very much. The project sounds like it was very successful. Is it still going?

Dr Jeffries-Stokes —We are working to expand it to the whole of the Goldfields now, to 10 communities over three years. We are working to get the funding for that. We had no problem getting the arts funding but, sadly, the health funding is extremely difficult to secure. There has been very little commitment from state and federal Health.

Ms HALL —That is an important message for us.

Dr Jeffries-Stokes —Yes. The way we want to do it is to set up two trucks. One will have all the art gear and the health promotion and one that is a mobile clinic, because we found that going to the communities and taking all the gear is very time-consuming, and there is often no place where you can actually set up. So if we have a truck that is a clinic, we just roll up and people can walk in. It works out to be quite cheap. They would be manned by four Aboriginal health workers who are trained not only in health but are also artists. We have started training Aboriginal health workers in this method of using community arts for health promotion, but getting the health funding has proved very difficult.

Ms HALL —That is an important message for us, I think, as a committee. Are the community gardens still going?

Dr Jeffries-Stokes —The way we did the gardening was not so much community gardens, because they have failed in the past, but we taught people how to set up household gardens, growing things in pots, and school gardens. Now all the schools have fruit trees in their yards and they have school gardens growing vegetables, and lots of people are growing stuff at home.

Ms HALL —That is very innovative, isn’t it?

Dr Jeffries-Stokes —One of the problems that we face is that, with the resources boom, all the able-bodied men and women are working in the mine. We are left at home with the children and the people who are not very well or who are older, so we cannot do big-scale stuff; it has to be small-scale stuff. But it is also very rewarding for those people who may not be feeling very productive, very useful or very valued, because they can be the ones that grow stuff, who stand there with a hose and water it.

Ms HALL —My next question goes to maternal and child health care: breastfeeding.

Dr Jeffries-Stokes —There are very high rates of breastfeeding throughout the Goldfields and the Central Desert. We have extremely high rates of lactose intolerance in the Aboriginal community, and this issue has been a particular interest of mine. Studies from the Kimberley in the seventies by Michael Gracey showed that over 70 per cent of Aboriginal children were lactose intolerant. In my own practice that has also been a big feature.

Aboriginal children in the Central and Western Deserts have the highest rate of kidney stones in the world, particularly in the under three age group, and we have not been able to find a reason for that. They do not have any identifiable reason, but it seems that that is due to chronic metabolic acidosis as a result of lactose intolerance. Lactose intolerance occurs even if you are breastfed but often it is after you have had antibiotics or after a change in environment or water. So we have been very proactive with encouraging, if babies are not breastfed, the use of lactose-free infant formula. If they are breastfed and they develop diarrhoea or a sore bottom, which is a very good sign of lactose intolerance, we provide Lacteeze drops, which is lactase enzyme, which gets rid of the lactose in the milk. In fact, we have not had a case of renal stones for five years now, I think, in the Goldfields. We have very low rates of admission for diarrhoea or illness, whereas in the past we used to have very high rates of admission for diarrhoea or illness.

I know from working with the Institute for Child Health Research—and I became aware of this because my own child developed lactose intolerance and then her cousin accidentally had an ultrasound which showed renal stones; this all happened about 12 years ago now—that the data shows a rise in the reporting of renal stones from the Goldfields and then a fall, and in the other areas it is mirroring that as the word spreads about the treatment for lactose intolerance. An article about that was published in the Journal of Paediatrics and Child Health in about 1998 in my name. I rarely see failure to thrive any more and, if I do, it is generally due to lactose intolerance, and a very few cases of actual neglect, but that is very rare.

Ms HALL —Are the World Health Organisation guidelines observed—the six months exclusive breastfeeding—or is there the introduction of other things along the way?

Dr Jeffries-Stokes —As a paediatrician, I have a difficulty with the six months exclusive breastfeeding thing, because the introduction of solids is actually a developmental stage. So it should be when the children are developmentally ready, and you do not introduce everything. When children start to watch what you are eating and want to put things in their mouths, they might as well put food in their mouths as anything else, because that is what they want to do. If you miss that stage, you often have difficulty teaching them to eat, because they become orally defensive.

The World Health Organisation guidelines really arose because people were stopping breastfeeding when they started solids. In fact, the message was supposed to be, ‘Don’t stop breastfeeding till at least six months.’ Because people did not really understand that and were stopping breastfeeding when they started solids, they made it exclusive breastfeeding for six months, but that is probably not the best thing for many children. Many children are ready for solids at four months and should start them then. But Aboriginal people do not have any idea about those guidelines in general. They introduce solids when the children are ready, and that works very well.

Ms HALL —Has breastfeeding increased in the communities where you are or has it always been high?

Dr Jeffries-Stokes —It has always been high. Aboriginal women have always breastfed. It is the normal thing to do, except when children are cared for by someone else. We still have a lot of families where children will be breastfed by more than one person, which would be normal—by the mother’s sisters or cousins—so breastfeeding rates are still very high.

CHAIR —They are quite high. We conducted an inquiry into breastfeeding in the last parliament, which Jill and I were both a part of, and the impression was that breastfeeding rates were not high in the Aboriginal community, and when we did go out and see them, we discovered otherwise.

Ms HALL —Yes.

CHAIR —I think it is a common thing around Australia among Aboriginal people, especially out in the communities.

Dr Jeffries-Stokes —Yes. Often children are breastfed and other things as well, particularly if they are at times left with other people. Then they are given a bottle of milk from a cup.

Ms HALL —I am interested in the connection between that early childhood start and then later health implications. It does not seem to have the same flow-through in Aboriginal communities as it does in the general community where there is a fair amount of scientific research that shows a breastfed baby tends to be a healthier baby, whereas you have still got these chronic health problems in Indigenous communities. Can you give me an explanation for that?

Dr Jeffries-Stokes —You have to look at the health of the mothers—

Ms HALL —Yes, that is what I thought.

Dr Jeffries-Stokes —and the in utero factors. I do really wonder about, and I would like to set up a study looking at, the omega-3 thing. From the dietary information, we know folate intake is probably pretty poor in pregnancy, which will have an impact on the child. Omega-3 impact is probably very important as well and we wonder if omega-3 is in some ways protective particularly for things like foetal alcohol syndrome. We are starting to look at that. If you have a population that for many generations has been on a diet high in omega-3 and you suddenly take that away over two generations, then it is probably going to have a very significant impact on the children.

In our study we found that six per cent of people were anaemic. Anaemia is a last sign of iron deficiency, so iron deficiency is a problem. Maternal iron deficiency during pregnancy is common in Aboriginal women, so the babies will have poor iron stores as well. Iron is very important for brain growth and also for your immune system. It is critical to the formation not only of red blood cells but also white blood cells that fight infection. So a lot of babies have a whole lot stacked against them before they are even born. Improving the health and nutrition of the mothers would probably make a major impact.

Ms HALL —That is good. Thank you.

CHAIR —There being no further questions, we thank you very much for presenting. Please feel free to feed any other information that you may have.

[11.54 am]