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Keywords:

  • aged care;
  • food services;
  • Indigenous population;
  • nutritional status;
  • remote

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Findings and discussion
  7. Conclusion
  8. Acknowledgements
  9. Key Points
  10. References

Objective

To describe the nutritional status of older Indigenous people, barriers to achieving optimal nutrition, and the effectiveness of programs aimed at improving nutrition in older Indigenous people in remote communities.

Methods

A comprehensive literature review was undertaken utilising electronic databases Scopus, CINAHL, Informit, Ovid MEDLINE, ProQuest, Web of Knowledge, PsycINFO, ATSI HealthInfoNet and Google Scholar. Grey literature was also accessed.

Results

Findings indicated there is a scarcity of representative data on nutritional status and risk in older Indigenous people, and nutrition support programs have not been evaluated.

Conclusions

Older Indigenous people suffer from poorer overall health and higher levels of overweight and obesity, and are at increased risk of poor nutritional status and malnutrition than the general population. This risk may be higher in remote areas. More representative data are needed to determine the nutritional status of older Indigenous people, including levels of malnutrition. Support programs also need to be evaluated.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Findings and discussion
  7. Conclusion
  8. Acknowledgements
  9. Key Points
  10. References

There is now a considerable body of literature on the nutritional issues and dietary needs of older people, which has been useful for policy-makers and service providers in the areas of ageing and aged care [1-5]. A focus on older adults in institutions (such as residential aged care) and community-based settings has occurred, including the specific needs of those from culturally and linguistically diverse backgrounds [1, 6-9]. This substantial research base has contributed to more effective targeting of nutrition interventions and programs aimed at maintaining or improving the nutritional status of vulnerable older people [1, 4, 6, 10, 11]. However, the literature to date has had little to say on the subject of Indigenous older people and nutrition, despite a substantial body of material relating to other Indigenous age groups and the Indigenous Australian population in general. This research gap is problematic in the context of aged care provision in remote areas, where service providers have little information and few resources to draw upon confidently to assist their practice in nutrition and meals services, compared with their counterparts in other service delivery contexts.

Good nutrition is vital to healthy ageing, and achieving optimal dietary intake is a common challenge among older people [2, 3, 12, 13]. Studies have found that in the general older population, height, weight and body mass index (BMI) decrease from the age of 70, and age-related changes can influence functional capacity, limit food intake, food choice and food variety, and result in poor nutritional status [2, 3, 13-17]. Gaining adequate or quality food intake is often a greater challenge for those living in poverty [13, 18].

Poor nutrition in older people has many known effects such as increased functional decline, longer hospital stays, and increased morbidity and mortality [16, 17, 19-22]. Improvements in nutrition can result in better health, functional ability, and longevity, and old age is not too late for dietary improvements to have a positive effect [23].

All older people have a right to a standard of living and care that enables optimal health and quality of life irrespective of race or geographical location [15, 24], including access to quality affordable food, cooking hardware, good sanitation, transport, health care and social support services, and functional housing free from overcrowding. However, the living situations, health and well-being of older Indigenous people are significantly worse than those of the general older population, particularly for those living in remote areas [25-29]. Older Indigenous people may also be significantly more at risk of poor nutrition and malnutrition compared with the general older population. It is the preference of many older Indigenous people to stay ‘in the country’ until they ‘finish up’.1 They have a key role as custodians of cultural knowledge with a central role in kinship networks [30], but have shorter life expectancies than their non-Indigenous peers, with 74% of Indigenous men and 64% of Indigenous women dying before the age of 65 [31]. Older Indigenous people may have their vital cultural and community roles (and end of life choices) compromised by poor health and nutritional status. We know anecdotally and from practice observations (KS) that many community care service providers in remote areas, such as Home and Community Care (HACC) staff, who are key to supporting older people to remain in the country, operate in relative isolation and have little knowledge of the nutritional needs or nutritional status of clients, or the effectiveness of their efforts in providing nutrition support to this group.

We have known for some time that poor nutrition exists among the Indigenous population and among the general older population [5, 32]. This paper explores the available evidence relating to older Indigenous people and nutrition in Australian remote communities, aiming to identify: (i) nutritional status of older Indigenous people; (ii) factors that may influence their nutritional status; and (iii) what is known about aged care service delivery issues associated with meeting the nutritional needs of older Indigenous people in remote communities.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Findings and discussion
  7. Conclusion
  8. Acknowledgements
  9. Key Points
  10. References

A comprehensive search of the literature was conducted in 2011, and updated in 2012. Electronic databases such as Scopus, CINAHL, Informit, Ovid MEDLINE, ProQuest, Web of Knowledge, PsycINFO, ATSI HealthInfoNet and Google Scholar were searched. Only articles written in English were included, and Aboriginal or Torres Strait Islanders in Australia were the focus. The following strategy was adapted across the databases: (Aged OR elder* OR old people OR geriatrics) AND (Indigenous or Aborig* or Oceanic ancestry group, Torres Strait Islanders) AND (nutrition OR diet OR nutritional status OR Nutrition requirements OR nutrition disorders OR malnutrition OR overnutrition OR food services or HACC OR Home and community care). Where available, MeSH headings were used. No date limits were set, and over 2000 titles were returned. These titles were reviewed and the abstracts of papers that related to one or more of the three aims of the study were retrieved. Because of a lack of studies on the topic of older Indigenous people and nutrition, snowballing and opportunistic search methods were then used. From these initial searches, subsequent reference list searches, and a search of grey literature – primarily from the Australian Institute of Health and Welfare, the Australian Bureau of Statistics and the National Health and Medical Research Council – we constructed a narrative review. We have also drawn on practice experience to highlight specific points.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Findings and discussion
  7. Conclusion
  8. Acknowledgements
  9. Key Points
  10. References

Only two primary research articles were found that related specifically to nutrition in older Indigenous people in remote communities [33, 34]. In the absence of articles specifically relating to the topic area, we drew on a broader range of literature to construct our narrative review. Information used to formulate the results was primarily extracted from several key references found to relate to one or more of the three research aims [25-27, 31, 32]. Three had direct relevance to the dietary intakes of older Indigenous people [25, 33, 34]. Some papers provided insight into the dietary intakes and aged care service delivery issues for older Indigenous people residing in remote Northern Territory, Australia [33-37].

Findings and discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Findings and discussion
  7. Conclusion
  8. Acknowledgements
  9. Key Points
  10. References

Older Indigenous Australians

Overall, the Australian Indigenous population has a younger age structure than the general population (in 2006, 12% of older Indigenous people were aged over 50, compared with 31% of the general population, and 3% were aged over 65 compared with 13%) largely due to higher fertility, lower life expectancy and higher mortality rates in the middle adult years [38]. People over 50 represent 11% of the Indigenous population (56 892). The age of 50 is used in current government policy (aged care service eligibility), to classify Indigenous people as ‘aged’ or ‘older’ (compared with 65 in the general population), in recognition of the sharp physical decline beyond age 45 and the higher level of need for care and services largely related to poor health associated with chronic disease [39].

Nutritional status and risk factors

Nutrition and health status

Nutritional status refers to the condition of the body in relation to diet and there is no single measure for the assessment of nutritional status. Practitioners frequently combine available information on anthropometry, haematology, biochemistry and dietary intake. Validated malnutrition screening tools are also commonly used in aged care (such as Mini Nutrition Assessment or Malnutrition Universal Screening Tool) as a quick measure to indicate whether the person is malnourished or at risk [40]. Using a variety of screening methodologies, a high prevalence of malnutrition has been found among older Australians in rehabilitation settings (20–50%), acute settings (20–50%), and residential aged care settings (40–70%) and in community-dwelling older people (5–40%) [1, 4, 5]. Rates of malnutrition may also be under recognised and under diagnosed in all of these settings [5].

Screening tools have not been validated for their effectiveness in detecting malnutrition or nutrition risk in the older Indigenous population. Poor nutritional status and malnutrition have been observed in dietetic practice in older Indigenous people in the Northern Territory in urban, remote and institutional contexts (KS). The skill level of aged/community care service providers in identifying malnutrition and designing appropriate and effective early interventions is unknown, and there are no points of reference or practice guidelines to assist with the identification of malnutrition in this population group.

Data from the 2004 National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) suggest that overweight and obesity is one of the biggest issues affecting the Indigenous population aged over 55 [25]. Using standard international BMI cut-offs (<18.5 underweight, 18.5–24.99 healthy, >25 overweight and >30 obese), findings indicate that among Indigenous people aged over 55, 34% are overweight and 39% are obese, 1.2 times higher than in the general population aged over 55. In the NATSIHS sample, 2.3% were found to be underweight (similar to the general population) and 24.1% in the healthy weight range. While these findings suggest over-nutrition, they are more likely to reflect energy dense, nutrient poor diets, and malnutrition could still be an issue.

National representative findings may not accurately reflect weight status in Indigenous populations and in some cases have underestimated levels of overweight and obesity in remote areas [41-43]. Data from the NATSIHS are based on self-reported height and weight. It has also been suggested that BMI inaccurately estimates adiposity in Indigenous people and may be better combined with waist circumference as a more accurate measure [42]. Furthermore, not reflected in the national data, studies in remote communities have noted a decline in the body mass of older people between the ages 55 and 74 years which may be a result of tradition-based behaviours that affect nutrient intakes [44]. It may also represent a cohort phenomenon where these older people experienced different dietary habits than their younger counterparts [44]. These older people who consumed a healthier diet early in their life may outlive the younger generations.

A majority of older Indigenous people are suffering from multiple chronic conditions. These conditions are known to become more prevalent with age; however, older Indigenous people experience earlier onset and higher prevalence of these conditions than the general older population [25, 45]. Older Indigenous people are 3 times more likely to suffer from diabetes (around 5–7 times higher in those aged 25–55), 4–12 times more likely to suffer from end stage renal disease, and 1.2 times more likely to suffer from hypertension (2–3 times higher in 25–44 age groups). Over half suffer from cardiovascular-related conditions, and overall they are more likely to be hospitalised for issues relating to the management of these conditions than the general older population [27]. Levels of modifiable risk factors are also significantly higher. Older Indigenous people are 1.5 times more likely to be inactive (80% over 55 report sedentary or low levels of exercise), smoke tobacco, and have a low intake of fruits and vegetables, all of which contribute significantly to the burden of disease and premature mortality [25, 27, 45]. Many of these conditions worsen with remoteness [27]. The presence of chronic diseases can also increase the risk of poor nutritional status and malnutrition. Many of the conditions experienced by older Indigenous people are likely to be comorbid [17, 45]. Malnutrition may also occur in addition to these issues, although this may not be reflected in the literature.

Despite extensive knowledge of the levels of disease in the Indigenous population, we have little understanding of how these issues, combined with suspected age-related nutritional issues, affect the older Indigenous person, particularly in remote communities. It is documented in the literature that poor health among Indigenous Australians has emerged as a result of change from traditional diet to a western style diet [32]. Poor diet can result in increased risk of morbidity and mortality and many older Indigenous people may lack understanding of their health conditions and dietary requirements, placing them at greater risk of poor nutritional status [45].

Nutrition risk and barriers to achieving optimal nutrition intake

There seems sufficient evidence to suggest that older Indigenous people may be at greater risk of poor nutritional status and malnutrition than the general older population due to a range of broad social, political and economic factors [32]. These include higher levels of poverty, financial pressure, welfare dependence and economic abuse [26, 27, 32, 46]; poorer housing and sanitation, lack of adequate cooking facilities and overcrowding [27, 47]; social factors such as changes in roles, responsibilities and social status, and higher levels of carer burden and care responsibility [27, 32]; and geographical location where rural and remote locations experience heightened food insecurity associated with higher food costs and poor food quality, variety and availability [48]. Older Indigenous Australians also experience significantly higher rates of functional decline, disability, cognitive impairment, and mental health problems, and higher levels of stress, abuse and neglect [25, 27, 46]. Poor dental health is also experienced, with greater tooth loss and denture requirements [25, 27]. Many of these physical issues can hinder dietary intake, but may be overcome with the right knowledge and skills, and with access to professional support. Aged care programs such as HACC are well placed to alleviate the burden of many of the social, environmental and physical challenges in remote communities. However, many of these challenges may also impact on the success of such programs in improving food security. For example, it is not uncommon for meals delivered by aged care programs to be shared among family or consumed by dogs rather than by the older people for whom they were intended [37].

The literature highlights that community dwelling older people in the general population who are housebound or have low incomes have an increased risk of poor nutrition and food insecurity [13]. Internationally, higher levels of nutrition risk have been found among minority group older people experiencing social isolation, poor social support and low social capital [49]. Comparatively poor nutrient and energy intakes and poorer nutritional status have also been identified in Indigenous people in poor and developing countries [50, 51]. Furthermore, older people experiencing functional decline and disease are said to be at increased levels of nutrition risk [5, 16]. Many of these issues can be applied to older Indigenous Australians [26, 28, 29, 32, 47, 52].

Dietary patterns

Data on the dietary patterns of older Indigenous people suggest that they may be at risk of poor nutritional status, and undernutrition, due to poor quality diet and low consumption of foods from the core food groups. Studies of both urban and remote Indigenous Australians have found diets to be high in fat, saturated fat and refined carbohydrates, low in fruits and vegetables, and lacking in several micronutrients [25, 35, 36, 53]. These studies found that a large portion of energy is contributed by sugar, flour, bread and fatty meat, reflective of conditions of poverty [35, 36]. The Food Habits in Later Life study of 54 older Indigenous people in Junguwa in 1988 found they had a ‘feast and famine’ eating pattern linked to the pension pay cycle [34]. They consumed on average 16 800 kJ/day, with intakes of 25 200 kJ on feast days and as little as 4200 kJ on famine days [33, 34]. In general, intakes of less than 2 meals per day in those over 65 have been associated with inadequate nutrient intakes [8, 54].

Generally, diets of Indigenous people in urban centres have been found to reflect the diets of those living in poverty (energy dense and nutrient poor), and include high amounts of takeaway foods [32]. Low levels of plasma carotenoids (biomarkers of fruit and vegetable intakes) have been found among urban Indigenous people [53]. The diets of older Indigenous people in urban settings have not been studied independently.

The current dietary guidelines for Australian adults recommend that men and women aged over 60 consume 4–7 and 6–12 servings of breads and cereals, 5 servings of vegetables, 2 servings of fruits, 2 servings of dairy and 1 serving of lean meat per day [55]. Data from the NATSIHS show older Indigenous people may not be meeting these targets for fruits and vegetables, and greater food insecurity is evident [25]. The survey found that compared to the general population, Indigenous people aged over 55 were more likely to consume whole milk (a marker of saturated fat intake), and less likely to consume the recommended daily intakes for fruits and vegetables. However, compared with their younger counterparts, Indigenous people aged over 55 were more likely to consume 2 or more servings of fruit per day [25, 55]. This was also found in the Junjuwa study in 1988 and may be associated with the provision of meals through the HACC program.

Nutrient reference values were updated in Australia in 2005; the supporting guidelines set dietary targets for two groups of older people, recommending that men and women aged 51–70 and 70+ should double their intakes of meat and dairy [56]. These targets may be difficult to attain in a population group that is already struggling to meet the existing dietary targets. Food insecurity seems evident from the 2004 to 2005 NATSIHS [25]. Indigenous people aged over 55 were about 10 times more likely to run out of food than the general older population. This trend occurred across age groups but was highest among those over 55.

Food preferences of older Indigenous people may relate to early life experiences as well as current food supply. Menu planning in this complex cross-cultural environment is difficult with limited information available about the actual food preferences of older Indigenous people. If preferences are consistent with findings in the Junjuwa 1988 study and current trends on food purchases in Indigenous communities [33-36], then it may be difficult to nourish this group appropriately.

Interventions and programs supporting the nutritional needs of older community-dwelling Indigenous people

Aged care programs

HACC and Community Aged Care Packages are the main providers of meals services in remote Northern Territory, and meals provision is by far the most common aged care service [37]. However, as in other jurisdictions, these services must comply with the program eligibility criteria related to the needs of the individual and carers and they are not intended to prop up poor food resources in the community. To date, there has been no evaluation of the effectiveness of these community care programs in meeting the nutritional needs of older Indigenous people. Within these programs, there are no set guidelines or nutritional policies specifying types and amounts of foods to be provided in the programs, nor any policy requirement to screen for nutritional risk. Considerable variation in meals services provided by remote aged care centres has been noted [37].

HACC services have been suggested as a useful preventative health-care model and may provide an opportunity for health and nutritional improvement in the eligible older population [57]. In the general older population, the HACC program has been used as a mechanism for increasing nutrition screening, and initiating a pathway for nutritional improvement, and it has resulted in successful improvements in nutritional status [1]. The implementation of malnutrition screening using a validated assessment tool can successfully identify those at risk of malnutrition in the community, and facilitate timely referral to nutrition support [5]. Nutrition screening followed by intensive dietetics support has been shown to be effective in improving the nutritional status of malnourished older people [1, 11]. In Victoria, nutrition risk screening is recommended to take place at the same time as a client needs assessment [58]. Meals programs that provide 100% of Recommended Dietary Intakes (RDI) compared to 33% of RDI have resulted in significant nutrition improvement among older people found to be at risk of malnutrition [10]. Some states in Australia have set nutrition criteria to ensure the nutritional quality of meals provided by the HACC (Meals on Wheels) programs [58, 59].

Professional support

Allied health staff have a role to play in preventing or reducing morbidity and mortality associated with chronic disease. The Central Australian Allied Health Planning Study found inequity in the levels of all allied health professionals available to assist people in remote areas in Australia compared with capital cities [60]. The study highlighted a significantly increased need for more professionals to meet the needs of remote areas, and comply with national standards. In other states of Australia, HACC dietitians are appointed to provide direct care, training and service delivery improvements. However, there is a paucity of data about the availability, uptake and effectiveness of nutrition-related professional support for program delivery or assessment of older people in remote aged care programs.

Resources and guidelines

The dietary guidelines for Australian adults set targets for the healthy older people, but are not intended to address the issues faced by frail older people [55]. The Aboriginal Torres Strait Islander Guide to Healthy Eating also does not address the needs of the older, or frail older, population [61]. The World Health Organisation recognises the importance of food-based dietary guidelines specific to a target group to help convey nutrition messages and the need to overcome barriers to obtaining optimal nutrition, and recommends that environmental, social, economic and lifestyle factors be considered in developing methods to improve the relevance and effectiveness of nutrition-based messages [13]. There seems a lack of guidance to assist aged care staff in remote Indigenous communities to assist with catering to the nutritional needs of their client group.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Findings and discussion
  7. Conclusion
  8. Acknowledgements
  9. Key Points
  10. References

The available literature suggests older Indigenous people in remote areas may be at high risk of poor nutritional status and malnutrition, due to socioeconomic circumstances, poor living conditions, geographical location, poor health and low mobility. To date, there are few representative data on issues such as nutrient deficiencies or excesses or malnutrition. Most of the available data detail excessive levels of overweight and obesity and chronic diseases. We have little understanding of the effects of these conditions, and suspected age-related issues, on the nutritional status of older Indigenous people.

We know little about the effectiveness of services that provide nutrition support to older Indigenous people or the possible disparity in access to professional support and resources to assist with nutrition improvement. This research gap is problematic in the context of aged care provision in remote areas where service providers have little information and few resources to confidently draw upon compared to their counterparts in other service delivery contexts. Aged care programs such as HACC have a role in providing nutritional improvements to the eligible population through provision of appropriate meals and incorporation of nutrition screening and improvement programs. To achieve this, research is required to determine the nutritional status of older Indigenous people, including levels of malnutrition and the number of frail older people in remote areas requiring specialised nutrition support. This will require validation of appropriate nutrition screening tools for use in these settings and a determination of the practical issues and effectiveness of aged care programs in providing nutritional improvements.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Findings and discussion
  7. Conclusion
  8. Acknowledgements
  9. Key Points
  10. References

The authors would like to acknowledge the assistance of Ms Di Bell and Professor John Wakerman.

This paper is an output of the Centre of Research Excellence in Rural and Remote Primary Health Care.

Key Points

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Findings and discussion
  7. Conclusion
  8. Acknowledgements
  9. Key Points
  10. References
  • Older Indigenous people may be at greater risk of poor nutrition than the general older population due to socioeconomic disadvantage, geographical isolation, food insecurity, and comparatively poorer health and functioning.
  • Community care meals programs for older people have not been evaluated in remote contexts so the effectiveness of these support programs in providing nutritional improvements is unknown. Programs in remote communities may lack professional nutrition support needed to assist with individual nutrition concerns.
  • Regular nutrition screening and protective nutrition guidelines incorporated in Home and Community Care programs have been able to provide nutrition improvement and quality assurance to older people in the general eligible population and for culturally and linguistically diverse groups, but to date this has not taken place in the area of Indigenous aged care.
  • More research is needed to determine the nutrition issues in older Indigenous people including the prevalence of malnutrition.
Footnotes
  1. 1

    This is an expression sometimes used by Aboriginal people meaning to die.

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  3. Introduction
  4. Method
  5. Results
  6. Findings and discussion
  7. Conclusion
  8. Acknowledgements
  9. Key Points
  10. References
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