Improvements in circulating cholesterol, antioxidants, and homocysteine after dietary intervention in an Australian Aboriginal community

Yarning about Diet: The Applicability of Dietary Assessment Methods in Aboriginal and Torres Strait Islander Australians-A Scoping Review

Conventional dietary assessment methods are based predominately on Western models which lack Aboriginal and Torres Strait Islander knowledges, methodologies, and social and cultural contextualisation. This review considered dietary assessment methods used with Aboriginal and Torres Strait Islander populations and assessed their applicability. Four electronic databases and grey literature were searched with no time limit applied to the results. Screening, data extraction and quality appraisal were undertaken independently by two reviewers. Out of 22 studies, 20 were conducted in rural/remote settings, one in an urban setting, and one at the national population level. The most frequently used and applicable dietary assessment method involved store data. Weighed food records and food frequency questionnaires had low applicability. Modifications of conventional methods were commonly used to adapt to Indigenous practices, but few studies incorporated Indigenous research methodologies such as yarning. This highlights an opportunity for further investigation to validate the accuracy of methods that incorporate qualitative yarning-based approaches, or other Indigenous research methodologies, into quantitative data collection. The importance of developing validated dietary assessment methods that are appropriate for this population cannot be understated considering the high susceptibility to nutrition-related health conditions such as malnutrition, overweight or obesity, diabetes, and cardiovascular disease.

Healthy lifestyle initiatives for increasing fruit and vegetable intake among Aboriginal and Torres Strait Islander peoples

Adequate fruit and vegetable intake is key to reducing chronic disease risk among Australian Aboriginal and Torres Strait Islander peoples. This rapid review collated evidence on healthy lifestyle initiatives that focused on increasing fruit and vegetable intake among Australian Aboriginal and Torres Strait Islander peoples residing in major cities. Due to limited studies conducted within major cities, we extended our inclusion criteria to regional and remote areas. Sixteen studies were included. Five (31%) studies were rated as good quality (least risk of bias), 10 (63%) studies were rated as fair, and 1 (6%) study was rated as poor (significant risk of bias). Five (31%) studies employed participatory research in the design and/or execution, and 7 (44%) studies included minimal community involvement. Only 5 (31%) studies were undertaken in major cities; 4 of these combined major cities with regional and/or remote areas. All 5 studies reported positive findings, such as an increase in fresh fruit availability, usage of fresh vegetables, or self-reported fruit and vegetable intake. This review provides evidence confirming the need for high-quality healthy lifestyle initiatives to increase fruit and vegetable intake targeted at Aboriginal and Torres Strait Islander peoples living in major cities. This evidence will assist community organisations in designing effective health promotion interventions, providing insight into improving the structure and function of such programs. PROSPERO registration number: CRD42020194522. Novelty Five studies were undertaken in major cities and all reported positive findings; only 1 study was rated as good quality. Presented data supports the need for high-quality studies to be conducted among those residing in major cities.

Effects of Nutritional Interventions on Cardiovascular Disease Health Outcomes in Aboriginal and Torres Strait Islander Australians: A Scoping Review

Nutrition interventions can support Aboriginal and Torres Strait Islander peoples to reduce their risk of cardiovascular disease (CVD). This review examines nutritional interventions aiming to improve CVD outcomes and appraises peer-reviewed interventions using an Aboriginal and Torres Strait Islander Quality Appraisal Tool. Five electronic databases and grey literature were searched, applying no time limit. Two reviewers completed the screening, data extraction and quality assessment independently. The study quality was assessed using the South Australian Health and Medical Research Institute and the Centre of Research Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange Aboriginal and Torres Strait Islander Quality Appraisal Tool (QAT). Twenty-one nutrition programs were included in this review. Twelve reported on anthropometric measurements, ten on biochemical and/or hematological measurements and sixteen on other outcome domains. Most programs reported improvements in measurable CVD risk factors, including reduced body mass index (BMI), waist circumference (WC), weight, blood pressure and improved lipid profiles. Most programs performed well at community engagement and capacity strengthening, but many lacked the inclusion of Indigenous research paradigms, governance and strengths-based approaches. This review highlights the need for contemporary nutrition programs aimed at improving cardiovascular health outcomes to include additional key cultural components.

Antioxidant biomarkers and cardiometabolic risk markers in an Aboriginal community in remote Australia: a cross-sectional study

OBJECTIVE

High-quality diets, characterised by nutrient-rich foods, are one of the foundations for health and well-being. Indicators of diet quality, antioxidants, are associated with protection against cardiometabolic diseases. The current study explores relationships between plasma antioxidants and cardiometabolic risk among Aboriginal people in Australia.

DESIGN

As part of a community-driven health promotion programme, we conducted a cross-sectional study including a health-behaviour questionnaire, plasma antioxidants and cardiometabolic risk markers (anthropometric, blood pressure measurements, fasting glucose, glycated Hb (HbA1c), lipids, C-reactive protein and albumin-creatinine-ratio) continuous and categorised into population-specific cut-offs. Antioxidants (β-carotene, β-cryptoxanthin, lycopene, lutein-zeaxanthin, retinol and α-tocopherol measured using HPLC) were applied to a principal component analysis, which aggregated these into a single component. Linear regression models were applied to investigate associations between the antioxidant component and cardiometabolic risk markers.

SETTING

Community in a remote area in Northern Territory, Australia.

PARTICIPANTS

A total of 324 Aboriginal people, mean age 35·5 (range 15-75) years.

RESULTS

Antioxidant component levels were higher among individuals with higher self-reported vegetable intake (P < 0·01), higher among individuals with higher self-reported fruit intake (P = 0·05) and lower among current smokers (P = 0·06). Linear regression revealed an inverse association between the antioxidant component and C-reactive protein (β = -0·01, P < 0·01) after adjusting for confounders.

CONCLUSION

Higher plasma antioxidant levels, indicators of diet quality, were associated with lower levels of high-sensitivity C-reactive protein in this Aboriginal population in remote Australia. This association suggests plasma antioxidants may be protective against inflammation; however, longitudinal studies are needed to examine this potentially protective relationship.

The Retail Food Sector and Indigenous Peoples in High-Income Countries: A Systematic Scoping Review

Indigenous Peoples in high-income countries experience higher burdens of food insecurity, obesity, and diet-related health conditions compared to national averages. The objective of this systematic scoping review is to synthesize information from the published literature on the methods/approaches, findings, and scope for research and interventions on the retail food sector servicing Indigenous Peoples in high-income countries. A structured literature search in two major international databases yielded 139 relevant peer-reviewed articles from nine countries. Most research was conducted in Oceania and North America, and in rural and remote regions. Several convergent issues were identified across global regions including limited grocery store availability/access, heightened exposure to unhealthy food environments, inadequate market food supplies (i.e., high prices, limited availability, and poor quality), and common underlying structural factors including socio-economic inequality and colonialism. A list of actions that can modify the nature and structure of retailing systems to enhance the availability, accessibility, and quality of healthful foods is identified. While continuing to (re)align research with community priorities, international collaboration may foster enhanced opportunities to strengthen the evidence base for policy and practice and contribute to the amelioration of diet quality and health at the population level.

Effects of food policy actions on Indigenous Peoples' nutrition-related outcomes: a systematic review

INTRODUCTION

Indigenous Peoples worldwide endure unacceptable health disparities with undernutrition and food insecurity often coexisting with obesity and chronic diseases. Policy-level actions are required to eliminate malnutrition in all its forms. However, there has been no systematic synthesis of the evidence of effectiveness of food and nutrition policies for Indigenous Peoples around the world. This review fills that gap.

METHODS

Eight databases were searched for peer-reviewed literature, published between 2000 and 2019. Relevant websites were searched for grey literature. Articles were included if they were original studies, published in English and included data from Indigenous Peoples from Western colonised countries, evaluated a food or nutrition policy (or intervention), and provided quantitative impact/outcome data. Study screening, data extraction and quality assessment were undertaken independently by two authors, at least one of whom was Indigenous. A narrative synthesis was undertaken with studies grouped according to the NOURISHING food policy framework.

RESULTS

We identified 78 studies from Canada, Australia, Aotearoa/New Zealand and the USA. Most studies evaluated targeted interventions, focused on rural or remote Indigenous communities. The most effective interventions combined educational strategies with policies targeting food price, composition and/or availability, particularly in retail and school environments. Interventions to reduce exposure to unhealthy food advertising was the only area of the NOURISHING framework not represented in the literature. Few studies examined the impact of universal food policies on Indigenous Peoples' diets, health or well-being.

CONCLUSION

Both targeted and universal policy action can be effective for Indigenous Peoples. Actions that modify the structures and systems governing food supply through improved availability, access and affordability of healthy foods should be prioritised. More high-quality evidence on the impact of universal food and nutrition policy actions for Indigenous Peoples is required, particularly in urban areas and in the area of food marketing.

Limited dietary interventions in rural Australian communities: A systematic review

AIM

This review aimed to synthesise the evidence on the effectiveness of dietary interventions targeting adolescents (>13 years) and adults living in rural or remote Australia.

METHODS

Six electronic databases were searched to identify dietary interventions undertaken in rural or remote communities. Studies were included if they utilised intervention and control comparisons or pre and post assessment of diet-related outcomes. If studies included metropolitan populations, dietary outcome measures had to be provided separately for rural data.

RESULTS

In total, 14 articles from 12 unique studies met the criteria for inclusion and together provided incomplete coverage across all states of Australia, included intervention studies targeted diet to address obesity, cardiovascular disease, and high blood pressure or diabetes. No studies were focussed on reducing community malnutrition. All studies, with one exception, focussed specifically on rural adults, no interventions specifically targeted adolescents in rural areas. Only two studies documented the involvement of a dietitian in intervention development or delivery. All studies produced a significant outcome for either dietary intake, body mass index, waist circumference, or diet related biomedical risk factors for individuals located in rural or remote areas of Australia.

CONCLUSION

Dietary interventions in rural Australia are under-studied, especially among the adolescent population. This is despite the high level of preventable diet-related disease burden in rural and remote Australia. Existing evidence shows promise in improving dietary intakes, but further, large scale intervention research, with the involvement of dietitians, is urgently needed to improve the health of rural communities.

Effect of nutrition interventions on diet-related and health outcomes of Aboriginal and Torres Strait Islander Australians: a systematic review

OBJECTIVE

To review the literature on nutrition interventions and identify which work to improve diet-related and health outcomes in Australian Aboriginal and Torres Strait Islander people.

STUDY DESIGN

Systematic review of peer-reviewed literature.

DATA SOURCES

MEDLINE, PubMed, Embase, Science Direct, CINAHL, Informit, PsychInfo and Cochrane Library, Australian Indigenous Health InfoNet.

STUDY SELECTION

Peer-reviewed article describing an original study; published in English prior to December 2017; inclusion of one or more of the following outcome measures: nutritional status, food/dietary/nutrient intake, diet-related biomedical markers, anthropometric or health measures; and conducted with Australian Aboriginal and Torres Strait Islander people.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and applied the Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project. A purpose designed tool assessed community engagement in research, and a framework was applied to interventions to report a score based on numbers of settings and strategies. Heterogeneity of studies precluded a meta-analysis. The effect size of health outcome results were estimated and presented as forest plots.

RESULTS

Thirty-five articles (26 studies) met inclusion criteria; two rated moderate in quality; 12 described cohort designs; 18 described interventions in remote/very remote communities; none focused solely on urban communities; and 11 reported moderate or strong community engagement. Six intervention types were identified. Statistically significant improvements were reported in 14 studies of which eight reported improvements in biochemical/haematological markers and either anthropometric and/or diet-related outcomes.

CONCLUSIONS

Store-based intervention with community health promotion in very remote communities, fiscal strategies and nutrition education and promotion programmes show promise. Future dietary intervention studies must be rigorously evaluated, provide intervention implementation details explore scale up of programmes, include urban communities and consider a multisetting and strategy approach. Strong Aboriginal and Torres Strait Islander community engagement is essential for effective nutrition intervention research and evaluation.

PROSPERO REGISTRATION NUMBER

CRD42015029551.

Health and wellbeing outcomes of programs for Indigenous Australians that include strategies to enable the expression of cultural identities: a systematic review

Indigenous people have long maintained that strong cultural identities are critical to health and wellbeing. The purpose of this systematic review is to examine whether interventions that entail strategies to enable expression of cultural identities for Australian Indigenous peoples are associated with measurable improvements in health and wellbeing. Peer-reviewed articles that reported quantitatively expressed health and wellbeing outcomes involving Indigenous Australian participants only were included. The cultural intervention component was defined and assessed by Indigenous researchers on the team. A narrative analysis was conducted. The protocol was registered on PROSPERO (CRD42015027387). Thirteen articles describing eleven studies were identified, including one randomised control trial (RCT), one cluster RCT and two studies with non-randomised controls. Other studies reported on case series or cross-sectional studies. All except two studies described multiple intervention strategies. Eight studies showed significant improvement in at least one psychosocial, behavioural or clinical measure, with two showing a positive direction of effect and one showing no improvement. Publication bias may discourage researchers to report negative findings of these interventions. Although studies vary in quality, this review provides evidence that interventions that include opportunities for expression of cultural identities can have beneficial effects for Australian Indigenous peoples.

Nutritional predictors of successful chronic disease prevention for a community cohort in Central Australia

OBJECTIVE

To investigate biomarkers of nutrition associated with chronic disease absence for an Aboriginal cohort.

DESIGN

Screening for nutritional biomarkers was completed at baseline (1995). Evidence of chronic disease (diabetes, CVD, chronic kidney disease or hypertension) was sought from primary health-care clinics, hospitals and death records over 10 years of follow-up. Principal components analysis was used to group baseline nutritional biomarkers and logistic regression modelling used to investigate associations between the principal components and chronic disease absence.

SETTING

Three Central Australian Aboriginal communities.

SUBJECTS

Aboriginal people (n 444, 286 of whom were without chronic disease at baseline) aged 15-82 years.

RESULTS

Principal components analysis grouped twelve nutritional biomarkers into four components: 'lipids'; 'adiposity'; 'dietary quality'; and 'habitus with inverse quality diet'. For the 286 individuals free of chronic disease at baseline, lower adiposity, lower lipids and better dietary quality components were each associated with the absence at follow-up of most chronic diseases examined, with the exception of chronic kidney disease. Low 'adiposity' component was associated with absence of diabetes, hypertension and CVD at follow-up. Low 'lipid' component was associated with absence of hypertension and CVD, and high 'dietary quality' component was associated with absence of CVD at follow-up.

CONCLUSIONS

Lowering or maintenance of the factors related to 'adiposity' and 'lipids' to healthy thresholds and increasing access to a healthy diet appear useful targets for chronic disease prevention for Aboriginal people in Central Australia.

Cost-effectiveness of interventions to prevent cardiovascular disease in Australia's indigenous population

BACKGROUND

Cardiovascular disease is the leading cause of disease burden in Australia's Indigenous population, and the greatest contributor to the Indigenous 'health gap'. Economic evidence can help identify interventions that efficiently address this discrepancy.

METHODS

Five interventions (one community-based and four pharmacological) to prevent cardiovascular disease in Australia's Indigenous population were subject to economic evaluation. Pharmacological interventions were evaluated as delivered either via Aboriginal Community Controlled Health Services or mainstream general practitioner services. Cost-utility analysis methods were used, with health benefit measured in disability-adjusted life-years saved.

RESULTS

All pharmacological interventions produced more Indigenous health benefit when delivered via Indigenous health services, but cost-effectiveness ratios were higher due to greater health service costs. Cost-effectiveness ratios were also higher in remote than in non-remote regions. The polypill was the most cost-effective intervention evaluated, while the community-based intervention produced the most health gain.

CONCLUSIONS

Local and decision-making contextual factors are important in the conduct and interpretation of economic evaluations. For Australia's Indigenous population, different models of health service provision impact on reach and cost-effectiveness results. Both the extent of health gain and cost-effectiveness are important considerations for policy-makers in light of government objectives to address health inequities and bridge the health gap.

Food, food choice and nutrition promotion in a remote Australian Aboriginal community

Contemporary diets of Aboriginal people living in remote Australia are characterised by processed foods high in fat and sugar. Within the 'new' food system, evidence suggests many Aboriginal people understand food in their own terms but lack access to consumer information about store-purchased foods, and parents feel inadequate as role models. In a remote Australian Aboriginal community, purposive sampling identified adults who participated in semistructured interviews guided by food-based themes relating to the contemporary food system, parental guidance of children's food choice and channels through which people learn. Interpretive content analysis was used to identify salient themes. In discussions, people identified more closely with dietary qualities or patterns than nutrients, and valued a balanced, fresh diet that made them feel 'light'. People possessed basic knowledge of 'good' store foods, and wanted to increase familiarity and experience with foods in packets and cans through practical and social skills, especially cooking. Education about contemporary foods was obtained from key family role models and outside the home through community-based organisations, including school, rather than pamphlets and flip charts. Freedom of choice was a deeply held value; carers who challenged children's autonomy used strategic distraction, or sought healthier alternatives that did not wholly deny the child. Culturally safe approaches to information sharing and capacity building that contribute to the health and wellbeing of communities requires collaboration and shared responsibility between policy makers, primary healthcare agencies, wider community-based organisations and families.

Nutritional impacts of a fruit and vegetable subsidy programme for disadvantaged Australian Aboriginal children

Healthy food subsidy programmes have not been widely implemented in high-income countries apart from the USA and the UK. There is, however, interest being expressed in the potential of healthy food subsidies to complement nutrition promotion initiatives and reduce the social disparities in healthy eating. Herein, we describe the impact of a fruit and vegetable (F&V) subsidy programme on the nutritional status of a cohort of disadvantaged Aboriginal children living in rural Australia. A before-and-after study was used to assess the nutritional impact in 174 children whose families received weekly boxes of subsidised F&V organised through three Aboriginal medical services. The nutritional impact was assessed by comparing 24 h dietary recalls and plasma carotenoid and vitamin C levels at baseline and after 12 months. A general linear model was used to assess the changes in biomarker levels and dietary intake, controlled for age, sex, community and baseline levels. Baseline assessment in 149 children showed low F&V consumption. Significant increases (P< 0.05) in β-cryptoxanthin (28.9 nmol/l, 18%), vitamin C (10.1 μmol/l, 21%) and lutein-zeaxanthin (39.3 nmol/l, 11%) levels were observed at the 12-month follow-up in 115 children, although the self-reported F&V intake was unchanged. The improvements in the levels of biomarkers of F&V intake demonstrated in the present study are consistent with increased F&V intake. Such dietary improvements, if sustained, could reduce non-communicable disease rates. A controlled study of healthy food subsidies, together with an economic analysis, would facilitate a thorough assessment of the costs and benefits of subsidising healthy foods for disadvantaged Aboriginal Australians.

A review of programs that targeted environmental determinants of Aboriginal and Torres Strait Islander health

OBJECTIVE

Effective interventions to improve population and individual health require environmental change as well as strategies that target individual behaviours and clinical factors. This is the basis of implementing an ecological approach to health programs and health promotion. For Aboriginal People and Torres Strait Islanders, colonisation has made the physical and social environment particularly detrimental for health.

METHODS AND RESULTS

We conducted a literature review to identify Aboriginal health interventions that targeted environmental determinants of health, identifying 21 different health programs. Program activities that targeted environmental determinants of health included: Caring for Country; changes to food supply and/or policy; infrastructure for physical activity; housing construction and maintenance; anti-smoking policies; increased workforce capacity; continuous quality improvement of clinical systems; petrol substitution; and income management. Targets were categorised according to Miller's Living Systems Theory. Researchers using an Indigenous community based perspective more often identified interpersonal and community-level targets than were identified using a Western academic perspective.

CONCLUSIONS

Although there are relatively few papers describing interventions that target environmental determinants of health, many of these addressed such determinants at multiple levels, consistent to some degree with an ecological approach. Interpretation of program targets sometimes differed between academic and community-based perspectives, and was limited by the type of data reported in the journal articles, highlighting the need for local Indigenous knowledge for accurate program evaluation.

IMPLICATIONS

While an ecological approach to Indigenous health is increasingly evident in the health research literature, the design and evaluation of such programs requires a wide breadth of expertise, including local Indigenous knowledge.

Health outcomes of a subsidised fruit and vegetable program for Aboriginal children in northern New South Wales

OBJECTIVE

To evaluate the impact of a fruit and vegetable subsidy program on short-term health outcomes of disadvantaged Aboriginal children.

DESIGN, SETTING AND PARTICIPANTS

A before-and-after study involving clinical assessments, health record audits and blood testing of all children aged 0-17 2013s (n = 167) from 55 participating families at baseline and after 12 months at three Aboriginal community-controlled health services in New South Wales. All assessments were completed between December 2008 and September 2010.

INTERVENTION

A weekly box of subsidised fruit and vegetables linked to preventive health services and nutrition promotion at an Aboriginal Medical Service.

MAIN OUTCOME MEASURES

Change in episodes of illness, health service and emergency department attendances, antibiotic prescriptions and anthropometry.

RESULTS

There was a significant decrease in oral antibiotics prescribed (- 0.5 prescriptions/2013; 95% CI, - 0.8 to - 0.2) during 12 months of participation in the program compared with the 12 months before the program. The proportion of children classified as overweight or obese at baseline was 28.3% (38/134) and the proportion in each weight category did not change (P = 0.721) after 12 months. A small but significant increase in mean haemoglobin level (3.1 g/L; 95% CI, 1.4-4.8 g/L) was shown, although the proportion with iron deficiency (baseline, 41%; follow-up, 37%; P = 0.440) and anaemia (baseline, 8%; follow-up, 5%; P = 0.453) did not change significantly.

CONCLUSION

it and vegetable subsidy program was associated with improvements in some indicators of short-term health status among disadvantaged Aboriginal children. A controlled trial is warranted to investigate the sustainability and feasibility of healthy food subsidy programs in Australia.

Use of point-of-sale data to assess food and nutrient quality in remote stores

OBJECTIVE

To examine the feasibility of using point-of-sale data to assess dietary quality of food sales in remote stores.

DESIGN

A multi-site cross-sectional assessment of food and nutrient composition of food sales. Point-of-sale data were linked to Australian Food and Nutrient Data and compared across study sites and with nutrient requirements.

SETTING

Remote Aboriginal Australia.

SUBJECT

Six stores.

RESULTS

Point-of-sale data were readily available and provided a low-cost, efficient and objective assessment of food and nutrient sales. Similar patterns in macronutrient distribution, food expenditure and key food sources of nutrients were observed across stores. In all stores, beverages, cereal and cereal products, and meat and meat products comprised approximately half of food sales (range 49–57 %). Fruit and vegetable sales comprised 10.4 (SD 1.9) % on average. Carbohydrate contributed 54.4 (SD 3.0) % to energy; protein 13.5 (SD 1.1) %; total sugars 28.9 (SD 4.3) %; and the contribution of total saturated fat to energy ranged from 11.0 to 14.4% across stores. Mg, Ca, K and fibre were limiting nutrients, and Na was four to five times higher than the midpoint of the average intake range. Relatively few foods were major sources of nutrients.

CONCLUSIONS

Point-of-sale data enabled an assessment of dietary quality within stores and across stores with no burden on communities and at no cost, other than time required for analysis and reporting. Similar food spending patterns and nutrient profiles were observed across the six stores. This suggests potential in using point-of-sale data to monitor and evaluate dietary quality in remote Australian communities.

Carotenoids and Alzheimer's disease: an insight into therapeutic role of retinoids in animal models

Carotenoids play a pivotal role in prevention of many degenerative diseases mediated by oxidative stress including neurodegenerative diseases like Alzheimer's Disease (AD). The involvement of retinoids in physiology, AD pathology and their therapeutic role in vitro and in vivo has been extensively studied. This review focuses on the role of carotenoids like retinoic acid (RA), all trans retinoic acid (ATRA), lycopene and β-carotene in prevention of AD symptoms primarily through inhibition of amyloid beta (Aβ) formation, deposition and fibril formation either by reducing the levels of p35 or inhibiting corresponding enzymes. The role of antioxidant micronutrients in prevention or delaying of AD symptoms has been included. This study emphasizes the dietary supplementation of carotenoids to combat AD and warrants further studies on animal models to unravel their mechanism of neuroprotection.

Successful chronic disease care for Aboriginal Australians requires cultural competence

OBJECTIVE

To review the literature to determine the attributes of culturally appropriate healthcare to inform the design of chronic disease management (CDM) models for Aboriginal patients in urban general practice.

METHODS

A comprehensive conceptual framework, drawing on the Access to Care, Pathway to Care, Chronic Care, Level of Connectedness, and Cultural Security, Cultural Competency and Cultural Respect models, was developed to define the search strategy, inclusion criteria and appraisal methods for the literature review. Selected papers were reviewed in detail if they examined a chronic disease intervention for an Aboriginal population and reported on its evaluation, impacts or outcomes.

RESULTS

In the 173 papers examined, only 11 programs met the inclusion criteria. All were programs conducted in rural and remote Aboriginal community-controlled health services. Successful chronic disease care and interventions require adequate Aboriginal community engagement, utilising local knowledge, strong leadership, shared responsibilities, sustainable resources and integrated data and systems. These success factors fitted within the conceptual framework developed.

CONCLUSIONS

Research and development of culturally appropriate CDM models concurrently in both urban and rural settings will enable more rigorous evaluation, leading to stronger evidence for best practice. A partnership of mainstream and Aboriginal-controlled health services is essential to successfully 'close the gap'.

IMPLICATIONS

Findings will inform and guide the development, implementation and evaluation of culturally appropriate CDM in mainstream general practice and primary care.

Plasma carotenoids are associated with socioeconomic status in an urban Indigenous population: an observational study

BACKGROUND

Indigenous Australians experience poorer health than other Australians. Poor diet may contribute to this, and be related to their generally lower socioeconomic status (SES). Even within Indigenous populations, SES may be important. Our aim was to identify factors associated with plasma carotenoids as a marker of fruit and vegetable intake among urban dwelling Indigenous Australians, with a particular focus on SES.

METHODS

Cross sectional study in urban dwelling Indigenous Australians participating in the DRUID (Darwin Region Urban Indigenous Diabetes) Study. An SES score, based on education, employment, household size, home ownership and income was computed and plasma carotenoids measured by high performance liquid chromatography in 897 men and women aged 15-81 years (mean 36, standard deviation 15). Linear regression analysis was used to determine the relationship between SES and plasma carotenoids, adjusting for demographic, health and lifestyle variables, including frequency of intakes of food groups (fruit, vegetables, takeaway foods, snacks and fruit/vegetable juice).

RESULTS

SES was positively associated with plasma concentrations of lutein/zeaxanthin (p trend <0.001), lycopene (p trend = 0.001), α- and ß-carotene (p trend = 0.019 and 0.026 respectively), after adjusting for age, sex, glucose tolerance status, smoking, alcohol use, hypercholesterolemia, dyslipidemia, self-reported health, waist to hip ratio and body mass index. These associations remained after adjustment for self-reported frequency of intake of fruit, vegetables, takeaway foods and fruit juice, which all showed some association with plasma carotenoids. Even in the highest SES quintile, concentrations of all carotenoids (except lycopene) were lower than the mean concentrations in a non-Indigenous population.

CONCLUSIONS

Even within urban Indigenous Australians, higher SES was associated with higher concentrations of plasma carotenoids. Low plasma carotenoids have been linked with poor health outcomes; increasing accessibility of fruit and vegetables, as well as reducing smoking rates could increase concentrations and otherwise improve health, but our results suggest there may be additional factors contributing to lower carotenoid concentrations in Indigenous Australians.

Smoking, nutrition, alcohol and physical activity interventions targeting Indigenous Australians: rigorous evaluations and new directions needed

OBJECTIVE

To describe and critique methodological aspects of interventions targeting reductions in smoking, poor nutrition, alcohol misuse and physical inactivity (SNAP risk factors) among Indigenous Australians.

METHODS

An electronic search of eight databases and a manual search of reference lists of literature reviews and reference libraries for Indigenous-specific intervention studies published in peer-reviewed journals (January 1990 to August 2007) were undertaken. Alcohol, smoking, nutrition or physical activity needed to be the primary focus of the study and the intervention needed to specifically target Indigenous Australians.

RESULTS

Twenty studies were selected for inclusion in the review. Methodologically, few studies employed randomisation or a control group, most omitted important details (e.g. costs), some did not report process measures (e.g. attrition rates), and some did not use validated measures. Two-thirds of interventions were implemented at the community level and employed multiple strategies.

CONCLUSION

There is a need for more rigorous evaluations of interventions targeting reductions in SNAP risk factors among Indigenous Australians, and to establish the reliability and validity of measures to quantify their effect.

IMPLICATIONS

It may be beneficial for future Indigenous-specific intervention research to focus on the evaluation of secondary prevention to complement the current concentration of effort targeting primary prevention. Community-wide interventions, combining strategies of greater intensity for high risk individuals with those of less intensity targeting lower risk individuals, might also offer considerable promise.

Environments and cardiometabolic diseases in aboriginal populations

This review establishes the relevance and frames the relationship of environmental factors to cardiometabolic risk factors and disease in Aboriginal populations. Environmental factors operate at the level of communities or populations. They include contextual measures of places and compositional measures of populations which together constitute "risk conditions" affecting individual risk factors. Environmental factors have been implicated by contrasting Aboriginal and non-Aboriginal populations in cardiometabolic risk factors and outcomes, or by geographic contrasts of Aboriginal populations in remote, rural and urban regions. It is unclear whether heterogeneity in contextual or compositional factors between and within Aboriginal populations is associated with heterogeneity in cardiometabolic risk factors and outcomes. Empirical literature that links environmental factors and cardiometabolic outcomes in Aboriginal populations is critically reviewed for three postulated pathways of influence: (1) behaviour; (2) psychosocial factors; and (3) stress response axes. These pathways, represented as interdependent, can explain how and why environments are associated with cardiometabolic outcomes. The need remains, however, to develop a robust quantitative evidence base in cardiometabolic research aimed at enhancing knowledge of the specific environmental factors related to the cardiometabolic health of Aboriginal populations as well as explicating the underlying mechanisms by which environmental risk conditions 'get under the skin'.

Conference on "Multidisciplinary approaches to nutritional problems". Symposium on "Diabetes and health". Nutrition interventions for the prevention of type 2 diabetes

Diabetes mellitus is escalating globally and it is predicted that 200 million individuals worldwide will have diabetes by 2010 and 300 million by 2025. However, there is compelling evidence from many studies that for subjects with impaired fasting glucose or impaired glucose tolerance the presentation of type 2 diabetes can be delayed by lifestyle modification. The aim of the present review is to present a summary of lifestyle modification interventions that have included a dietary component in their overall diabetes prevention programme. Medline, allied health literature and diabetes journals were searched for peer-reviewed literature using the terms 'diet*' and 'diabetes' and 'intervention'. Inclusion criteria were: peer-reviewed studies from 1975 to 2008; a sample of at least fifty subjects; a healthy eating and/or physical activity component; prevention of diabetes as a primary goal. Generally, the participants were in a high-risk category for the development of diabetes. Outcomes were evaluated at two points in time (pre- and post-intervention) in terms of knowledge, behaviour change and clinical improvement, which included weight, blood pressure, BMI, body fat, waist circumference, waist:hip ratio and physiological and/or biochemical measures. Findings indicate that the most successful interventions combine individual dietary counselling with an activity component. Further factors predicting success are weight loss achieved, duration and intensity of the intervention and dietary compliance.

Changes in predictors and status of homocysteine in young male adults after a dietary intervention with vegetables, fruits and bread

BACKGROUND

Elevated plasma total homocysteine (p-tHcy) is associated with increased risk of cardiovascular disease, and an inverse association has been shown between the dietary intake of B-vitamins, B-vitamin profile and the concentration of p-tHcy.

AIM OF THE STUDY

The main objective of this investigation was to study the effect of a dietary intervention focusing on an increased intake of vegetables, fruits and bread. The effect of the dietary intervention was determined by the changes in plasma concentrations of tHcy, cysteine (cys), riboflavin, flavin adenine dinucleotide (FAD) and flavin mononucleotide (FMN) and serum concentrations of folate and vitamin B(12).

METHOD

An intervention study with duration of 5 months, including 541 male recruits from the Norwegian National Guard, Vaernes and a control group, including 209 male recruits from the Norwegian Army, Heggelia.

RESULTS

The dietary intervention resulted in decreased concentration of p-tHcy (-10%, P = 0.002), p-cys (-6%, P < 0.001) and FMN (-11%, P = 0.310) and increased concentration of riboflavin (+23%, P < 0.001) and FAD (+10%, P = 0.008) in the intervention group compared with the control group. The change in p-tHcy concentration was positively related to the change in the concentration of p-cys (P < 0.001) and FMN (P = 0.035) and inversely related to the change in concentration of folate (P = 0.021).

CONCLUSIONS

A dietary intervention program focusing on an increased intake of vegetables, fruits and bread showed a favourable effect on the concentration of p-tHcy and its metabolites. Our findings suggest that the changes in the concentration of p-cys, folate and FMN seem to be predictors of changes in the p-tHcy concentration.

Hospital admissions and length of stay for coronary disease in an Aboriginal cohort

BACKGROUND AND AIMS

Coronary disease (CHD)-related hospital admission is more common among indigenous than non-indigenous Australians. We aimed to identify predictors of hospital admission potentially useful in planning prevention programs.

METHODS AND RESULTS

Length of stay (LOS), interval between, and number of recurrent admissions were modelled with proportional hazards or negative binomial models using lifestyle data recorded in 1988-1989 among Aborigines (256 women, 258 men, aged 15-88years) linked to hospital records to 2002. Among 106 Aborigines with CHD, hypertension (hazard ratio (HR) 1.69, 95% CI 1.05-2.73); smoking (HR 1.90, 95% CI 1.02-3.53); consuming processed meat >4 times/month (HR 1.81, 95% CI 1.01-3.24); >6 eggs/week (HR 1.73, 95% CI 1.03-2.94); and lower intake of alcohol (HR 0.54, 95% CI 0.35-0.83) predicted LOS. Eating eggs (HR 1.05, 95% CI 1.01-1.09) and bush meats > or =7 times/month (HR 0.46, 95% CI 0.23-0.92) predicted interval between recurrent admissions. Hypertension (IRR 4.07; 95% CI 1.32-12.52), being an ex-drinker (IRR 6.60, 95% CI 2.30-19.00), eating red meat >6 times/week (IRR 0.98, 95% CI 0.97-0.99), bush meats >7 times/month (IRR 0.26, 95% CI 0.10-0.67), and adding salt to meals (IRR 3.16, 95% CI 1.12-8.92) predicted number of admissions.

CONCLUSION

Hypertension, alcohol drinking, smoking, and diet influence hospital admissions for CHD in Aboriginal Australians.

Australian Aboriginal people and Torres Strait Islanders have an atherogenic lipid profile that is characterised by low HDL-cholesterol level and small LDL particles

AIM

To characterise lipid profiles for Australian Aboriginal people and Torres Strait Islanders.

METHODS

Community-based, cross-sectional surveys in 1995-1997 including: 407 female and 322 male Australian Aboriginal people and 207 female and 186 male Torres Strait Islanders over 15 years old. A comparator of 78 female (44 with diabetes) and 148 male (73 with diabetes) non-indigenous participants recruited to clinical epidemiological studies was used. Lipids were determined by standard assays and LDL diameter by gradient gel electrophoresis.

RESULTS

Diabetes prevalence was 14.8% and 22.6% among Aboriginal people and Torres Strait Islanders, respectively. LDL size (mean [95% CI (confidence interval)]) was smaller (P<0.05) in non-diabetic Aboriginal (26.02 [25.96-26.07] nm) and Torres Strait Islander women (26.01 [25.92-26.09] nm) than in non-diabetic non-indigenous women (26.29 [26.13-26.44] nm). LDL size correlated (P<0.0005) inversely with triglyceride, WHR, and fasting insulin and positively with HDL-cholesterol. HDL-cholesterol (mean [95% CI] mmol/L) was lower (P<0.0005) in indigenous Australians than in non-indigenous subjects, independent of age, sex, diabetes, WHR, insulin, triglyceride, and LDL size: Aboriginal (non-diabetic women, 0.86 [0.84-0.88]; diabetic women, 0.76 [0.72-0.80]; non-diabetic men, 0.79 [0.76-0.81]; diabetic men, 0.76 [0.71-0.82]); Torres Strait Islander (non-diabetic women, 1.00 [0.95-1.04]; diabetic women, 0.89 [0.83-0.96]; non-diabetic men, 1.00 [0.95-1.04]; diabetic men, 0.87 [0.79-0.96]); non-indigenous (non-diabetic women, 1.49 [1.33-1.67]; diabetic women, 1.12 [1.03-1.21]; non-diabetic men, 1.18 [1.11-1.25]; diabetic men, 1.05 [0.98-1.12]).

CONCLUSIONS

Indigenous Australians have a dyslipidaemia which includes small LDL and very low HDL-cholesterol levels. The dyslipidaemia was equally severe in both genders. Strategies aimed at increasing HDL-cholesterol and LDL size may reduce high CVD risk for indigenous populations.

Migration and its impact on adiposity and type 2 diabetes

In this review, we discuss the impact of migration on the incidence and prevalence of obesity and type 2 diabetes mellitus (T2DM) in different ethnic groups and populations. We also analyze the determinants of such phenomena in view of the global increase in the migration and escalating prevalence of obesity and T2DM. The risk escalation of the obesity and T2DM followed a gradient, as migrants (Blacks, Hispanics, Chinese, South Asians, etc.) became more affluent and urbanized, indicating an important role of environmental factors. A stepwise increase in the prevalence of obesity in Blacks along the path of migration (5% in Nigeria, 23% in Jamaica, and 39% in the United States) is a classic example. Furthermore, South Asian migrants, who are particularly predisposed to develop insulin resistance and T2DM, showed nearly four times prevalence rates of T2DM than rural sedentee populations. Similar observations were also reported in intracountry migrants and resettled indigenous populations. The determinants were found to include nutrition transition, physical inactivity, gene-environment interaction, stress, and other factors such as ethnic susceptibility. However, certain contradictory trends were also seen in some migrant communities and have been explained by various phenomena such as healthy migrant effect, "salmon bias", and adherence to traditional diets. A review of the evidence suggests a critical role of environmental factors in conferring an increased risk of obesity and T2DM. The important contributory factors to this phenomenon were urbanization, mechanization, and changes in nutrition and lifestyle behaviors, but the role of stress and as yet unknown factors remain to be determined.

Diabetes in Indigenous Australians: possible ways forward

Reducing the burden of diabetes will require action well beyond the health service sphere.

Increased carotid intima-media thickness in remote and urban Indigenous Australians: impact of diabetes and components of the metabolic syndrome

OBJECTIVE

Indigenous Australians have rates of cardiovascular (CVD) mortality some seven to 10-fold higher than non-Indigenous Australians aged 25-64 years. We aimed to evaluate the impact of type 2 diabetes and components of the metabolic syndrome on carotid intima-media thickness (CIMT) as a marker of cardiovascular risk in Indigenous Australians living in remote and urban environments and in Australians of European ancestry.

DESIGN, PATIENTS AND MEASUREMENTS

CIMT was measured by high-resolution B-mode ultrasound imaging of the common carotid artery in 119 remote Indigenous, 144 urban Indigenous and 122 urban European Australians with and without diabetes.

RESULTS

In nondiabetic participants, CIMT was lowest in Europeans (mean (SD) 0.64 mm (0.10)), higher in urban Indigenous Australians (0.67 mm (0.12)) and highest in remote Indigenous Australians (0.73 mm (0.15), P < 0.001). CIMT was higher with diabetes with the same pattern observed between populations: 0.73 mm, 0.79 mm and 0.82 mm, respectively (P < 0.001). Traditional risk factors (age, male gender, blood pressure and HbA1c) explained 35-45% of the variance of CIMT within each population group. However, differences in CIMT between population groups were maintained after adjustment for these cardiovascular risks plus cholesterol and smoking (P < 0.001). Factor analysis revealed that variables of the metabolic syndrome, together with smoking and elevated C-reactive protein (CRP) and urinary albumin-creatinine ratio (ACR), are likely to explain the higher CIMT in Indigenous Australians (and the urban-remote gradient). Unmeasured variables (genetic, psychosocial and socioeconomic) may also contribute to higher CIMT in these populations.

CONCLUSION

Glycaemic control and metabolic syndrome components contribute significantly to premature atherogenesis in Indigenous Australians and we recommend that therapy should be targeted accordingly.

Increased arterial stiffness in remote Indigenous Australians with high risk of cardiovascular disease

OBJECTIVE

To assess central and peripheral arterial stiffness in Indigenous and European Australians with and without type 2 diabetes using applanation tonometry to obtain the augmentation index (AI) and pulse wave velocity (PWV).

METHODS

AI was assessed in 162 Indigenous Australians (60 with type 2 diabetes) participating in a population-based study and 121 Australians of European ancestry (38 with diabetes) of similar age and sex. PWV was assessed in a subgroup: n = 62 indigenous, n = 118 European participants.

RESULTS

The indigenous group had higher AI than the European group [mean (SD) 32 (12) versus 24 (12)%, P < 0.0001] and carotid-femoral PWV [8.4 (1.8) versus 7.1 (2.2) ms(-1), P < 0.0001]. There were no significant differences between groups regarding blood pressure and total cholesterol; however, indigenous individuals had higher fasting glucose, insulin, haemoglobin A1c, triglycerides, waist circumference (despite lower body mass index), and a higher prevalence of cigarette smoking. Fifty-five per cent of the variance in AI was explained on multiple regression analysis by age, sex, indigenous participant, heart rate, mean arterial pressure, height, triglycerides and waist circumference. Age, indigenous participant, heart rate, mean arterial pressure and antihypertensive medication explained 56% of the variance in PWV. Variables of the metabolic syndrome and smoking, C-reactive protein (CRP), homocysteine and heart rate clustered with indigenous status on factor analysis.

CONCLUSIONS

Indigenous Australians have higher indices of peripheral and central arterial stiffness than European Australians of similar age and sex. Factor analysis revealed that metabolic syndrome variables, smoking, CRP, homocysteine and heart rate clustered with 'indigenous participant' and may explain increased arterial stiffness in this group.

Health-related behaviours as predictors of mortality and morbidity in Australian Aborigines

OBJECTIVE

To examine predictors of coronary heart disease (CHD) and all-cause mortality in Aboriginal Australians.

METHOD

In 1988-89, a survey of Western Australian Aborigines (256 women, 258 men) aged 15-88 years documented diet, alcohol and smoking habits. Linkage to mortality and hospital admissions to the end of 2002 provided longitudinal data for modelling of coronary heart disease endpoints and all-cause mortality using Cox regression.

RESULTS

Coronary heart disease risk increased with smoking (HR 2.62, 95% CI: 1.19, 5.75), consumption of processed meats >once/week (HR 2.21, 95% CI: 1.05, 4.63), eggs >twice/week (HR 2.59, 95% CI: 1.11, 6.04) and using spreads on bread (HR 3.14. 95% CI: 1.03, 9.61). All-cause mortality risk was lower with exercise >once/week (HR 0.51, 95% CI 0.26, 1.05), increased in ex-drinkers (HR 3.66, 95% CI: 1.08, 12.47), heavy drinkers (HR 5.26, 95% CI: 1.46, 7.52) and with consumption of take away foods >nine times/month (HR 1.78, 95% CI 0.96, 3.29). Greater alcohol intake, smoking and adverse dietary choices clustered in 53% of men and 56% of women and increased risk of coronary heart disease (HR 2.1, 95% CI: 1.1, 4.0) and all-cause mortality (HR 2.3, 95% CI: 1.2, 4.2).

CONCLUSION

Lifestyle in Aboriginal Australians predicts coronary heart disease and all-cause mortality. Clustering of adverse behaviours is common and increases risk of coronary heart disease and death.

Differential association of C-reactive protein with adiposity in men and women in an Aboriginal community in northeast Arnhem Land of Australia

OBJECTIVE

To examine the relationship between C-reactive protein (CRP), adiposity and other metabolic abnormalities in an Aboriginal community in Northern Australia.

DESIGN

Cross-sectional analysis of data obtained between 2001 and 2003 from 379 Aboriginal people residing in a geographically isolated community.

RESULTS

Mean (95% CI) CRP in women and men was 4.06 cholesterol (3.53, 4.66) mg/l and 3.42 (2.94, 3.97) mg/l, respectively (P=NS). The prevalence of the metabolic syndrome (US National Cholesterol Education [corrected] Program (NCEP) definition) was significantly higher for women than men (41 vs 18%, chi (2)=20.94, P<0.001). C-reactive protein correlated strongly with adiposity in women (waist circumference, waist to hip ratio and body mass index; r>/=0.514, P<0.01) but much less strongly in men (r

CONCLUSIONS

High CRP levels in the surveyed population are consistent with the high prevalence of vascular disease morbidity and mortality in Aboriginal Australians. The relationship of CRP with increasing body fat was strong and consistent in women but not in men. Prospective studies are needed to elucidate the role of CRP (if any) as a predictive marker for cardiovascular events in this high-risk population.

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MESH Headings

• Adipose Tissue/metabolism
• Adult
• Body Mass Index
• Body Size/physiology
• C-Reactive Protein/analysis
• Cardiovascular Diseases/epidemiology
• Cross-Sectional Studies
• Female
• Humans
• Male
• Metabolic Syndrome/complications
• Metabolic Syndrome/epidemiology
• Metabolic Syndrome/metabolism
• Northern Territory/epidemiology
• Obesity/complications
• Obesity/epidemiology
• Obesity/metabolism
• Population Surveillance/methods
• Prevalence
• Risk Factors
• Sex Distribution

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Affiliation(s)

T Shemesh Menzies School of Health Research, Royal Darwin Hospital, Rocklands Drive Tiwi, Northern Territory, Australia.
K G Rowley
A Jenkins
J Brimblecombe
J D Best
K O'Dea

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Does the store-turnover method still provide a useful guide to food intakes in Aboriginal communities?

OBJECTIVE

To consider the application of the store-turnover method as a guide to assess food intake in remote Aboriginal communities.

METHOD

Food sources in a remote Aboriginal island community were documented. The contribution of quantifiable food sources to total community-level fresh fruit and vegetable availability was determined.

RESULTS

The store remains the single largest supplier of fruit and vegetables overall (54%), however its contribution varies depending on the subpopulation of interest. A store-turnover alone may significantly underestimate community-level dietary intake, depending on the contribution of other food sources.

CONCLUSIONS

Changes in the food supply in remote communities, coupled with methodological complexities inherent in the store-turnover method, challenge its application in a contemporary context.

IMPLICATIONS

A simplified version of the store-turnover method is needed that could be widely applied by community people and health practitioners seeking to initiate and monitor interventions to improve diet quality.

Leanness and type 2 diabetes in a population of indigenous Australians

OBJECTIVE

To determine the prevalence of type 2 diabetes and its risk factors in a population of indigenous Australians.

RESEARCH DESIGN AND METHODS

A cross-sectional study of 332 indigenous community residents aged 15 years and over with fasting blood samples and anthropometric measurements.

RESULTS

Almost half of the study population (47.3%) was extremely lean (BMI<22 kg/m(2)). Leanness was particularly pronounced in the youngest age group (15<20 years), 78% of which had a BMI<22 kg/m(2). The prevalence of diabetes was 12%. It was highest in those 45-54 years and declined in older aged people. No cases of diabetes were detected in those aged less than 30 years. Diabetes prevalence was strongly linked to BMI and age (age-adjusted odds ratio=24.1, 95% CI 6.0-96.5, p<0.001) for BMI>or=25 kg/m(2) versus BMI<22 kg/m(2). Those with the lowest diabetes risk profile are lean (BMI<22 kg/m(2)) and/or young (age 15-34 years).

CONCLUSIONS

These results highlight that strategies to prevent or delay the onset of diabetes should focus on the maintenance of leanness from adolescence and throughout adult life whilst young people are still in the process of forming lifelong habits.

Preventable chronic diseases among indigenous australians: the need for a comprehensive national approach

Chronic conditions such as diabetes, cardiovascular disease and heart disease represent a serious and escalating health burden for Indigenous populations across Australia. Social disadvantage, inactive lifestyle and poor nutrition are major contributors to chronic disease among Indigenous peoples. We have the knowledge base to reduce the devastating impact of early onset chronic diseases in those who already have the conditions, and to prevent or delay their onset in those who have not yet succumbed. This represents a major and urgent challenge to governments and Indigenous communities.

Kava use, dyslipidaemia and biomarkers of dietary quality in Aboriginal people in Arnhem Land in the Northern Territory (NT), Australia

Heavy kava use has been associated with sudden death in Aboriginal Australians in Arnhem Land (Northern Territory, Australia) where poor diets and a high incidence of premature coronary heart disease are known. Heavy kava users may suffer additional risk if further malnourished. Among 98 people (62 males, 36 females) in one community, 36 never used kava, 26 were past users, and 36 were continuing users. Across kava-using groups skinfold thickness, body mass index and body fat decreased. Total- and LDL-cholesterol were elevated in kava users compared to both former users and never users. HDL-cholesterol was higher in current users vs never users. Across kava-using groups, triglycerides, homocysteine and diet-derived antioxidant vitamins alpha-tocopherol and retinol, did not vary. Plasma carotenoid levels (indicative of vegetable and fruit intake) were very low, but when adjusted for plasma cholesterol, did not vary between kava-using groups. An obsession for kava drinking may mediate kava's direct effects on nutritional status.

Inflammation and vascular endothelial activation in an Aboriginal population: relationships to coronary disease risk factors and nutritional markers

OBJECTIVE

To describe the levels of inflammation and vascular endothelial activation in an Aboriginal community, and the relationship of these factors to coronary heart disease (CHD) risk factors and markers of nutritional quality.

DESIGN AND PARTICIPANTS

A cross-sectional survey of 95 women and 76 men participating in a chronic-disease prevention program.

SETTING

A remote Aboriginal community in Western Australia in 1996.

MAIN OUTCOME MEASURES

Concentrations of markers of inflammation (C-reactive protein [CRP]) and vascular endothelial activation (soluble E-selectin [sE-selectin]); presence of metabolic syndrome; concentrations of diet-derived antioxidants.

RESULTS

Participants exhibited very high plasma concentrations of CRP (mean, 5.4 mg/L; 95% CI, 4.6-6.3 mg/L) and sE-selectin (mean, 119 ng/mL; 95% CI, 111-128 ng/mL). Both CRP and sE-selectin concentrations were significantly higher in the presence of the metabolic syndrome. There were significant inverse linear relationships between concentrations of CRP and plasma concentrations of the antioxidants lycopene, beta-carotene, cryptoxanthin and retinol. Even stronger inverse associations were evident between concentrations of sE-selectin and lycopene, beta-carotene, cryptoxanthin and lutein.

CONCLUSIONS

Vascular inflammation and endothelial activation may be important mediators of elevated CHD risk in Aboriginal people. Inadequate nutrition and physical inactivity may contribute to this process.

Carotenoids: separation methods applicable to biological samples

Epidemiologic and clinical studies have shown that a high intake of vegetables and fruit, with consequently high intakes and circulating concentrations of carotenoids, is associated with reduced risk of cardiovascular and other chronic diseases. The antioxidant properties of carotenoids are thought to contribute to these effects. The analysis of carotenoids in plasma, foods and tissues has thus become of interest in studies examining the role of diet in chronic disease prevention and management. High-performance liquid chromatography with ultra-violet or photodiode array detection is most often employed in routine use. We review these and other current methods for carotenoid analysis and information on sample stability relevant to epidemiological studies. The carotenoids remain an important and intriguing subject of study, with relevance to prevention of several important "lifestyle-related" diseases. Research into their physiological functions and their use as dietary markers requires sensitive, accurate and precise measurement. Further advances in these methodological areas will contribute to basic, clinical and public health research into the significance of carotenoid compounds in disease prevention.

Food availability, cost disparity and improvement in relation to accessibility and remoteness in Queensland

This study is the first to describe disparity and change in the food supply between metropolitan, rural and remote stores by Accessibility/Remoteness Index of Australia (ARIA) category. A total of 92 stores (97% response rate) within five aggregate ARIA categories participated throughout Queensland in 2000. There was a strong association between ARIA category and the cost of the basket of basic foods, with prices being significantly higher (20% and 31% respectively) in the 'remote' and 'very remote' categories than in the 'highly accessible' category. The association with ARIA was less marked for fruit and vegetables than for other food groups, but not for tobacco and take-away food items. Basic food items were less available in the more remote stores. Over the past two years, relative improvements in food prices have been seen in stores in the 'very remote' category, with observed increases less than the consumer price index (CPI) for food. Some factors which may have contributed to this improvement are discussed.

Single nucleotide polymorphisms of thrifty genes for energy metabolism: evolutionary origins and prospects for intervention to prevent obesity-related diseases

The "thrifty" genotype and phenotype that save energy are detrimental to the health of people living in affluent societies. Individual differences in energy metabolism are caused primarily by single nucleotide polymorphisms (SNPs), some of which promote the development of obesity/type 2 diabetes mellitus. In this review, four major questions are addressed: (1) Why did regional differences in energy metabolism develop during evolution? (2) How do genes respond to starvation and affluence? (3) Which SNPs correspond to the hypothetical "thrifty genes"? (4) How can we cope with disease susceptibility caused by the "thrifty" SNPs? We examined mtDNA and genes for energy metabolism in people who live in several parts of Asia and the Pacific islands. We included 14 genes, and the SNP frequencies of PPAR gamma 2, LEPR, and UCP3-p and some other genes differ significantly between Mongoloids and Caucasoids. These differences in SNPs may have been caused by natural selection depending on the types of agriculture practiced in different regions. Interventions to counteract the adverse effects of "thrifty" SNPs have been partially effective.

Paraoxonase and other coronary risk factors in a community-based cohort

Oxidative damage to circulating lipids and vascular tissues contributes to the initiation and progression of atherosclerosis. High density lipoprotein provides protection from atherosclerosis and the enzyme paraoxonase may contribute to this effect. The aim of the present study was to examine the trends in paraoxonase activity during the course of a community-directed life-style intervention, and relationships of paraoxonase activity to other coronary heart disease risk factors, in a cohort of Australian Aboriginal people.