Harnessing the power, know‐how and capacity of those considered most vulnerable in designing and implementing policy

The differences in health that exist between different population groups are avoidable and unfair.1 They are largely determined by differences in access to economic resources, distribution of power, social policy and the values held by society.1 They impact many population subgroups including Indigenous people, young adults, the elderly and those living with medical conditions. Significant improvements in health could and must be made by addressing the social determinants that are mostly responsible for these avoidable and unfair health inequities. These social determinants are the ‘conditions in which people are born, grow, live, work and age’ (p. 189).1 Green and Kreuter2 and McLeroy et al.,3 introduced a socio-ecological theory that helped shift the focus of health promotion in the late 1980s/early 1990s on deficiencies in individual behaviour, to the environmental variables that were seen as largely shaping a person’s behaviour. This broad holistic perspective does not deny individual agency. Indeed, an important construct of socio-ecological theory is the notion of reciprocal determinism where we as individuals can in turn influence the broader systems of which we are a part.4 The power of people cannot be underestimated. Harnessing this power and supporting people’s capacity to advocate and be agents of change, can achieve environmental change that may otherwise not be possible. An example of this is Amata community in the Anangu Pitjantjatjara Lands, South Australia, who in 2008 removed top-selling sugary drinks from sale in their store when provided with evidence by a public health dietitian on the high sales of sugary drinks and amount of sugar from drinks purchased.5 The entry of ‘systems thinking’ into dietetics practice in the last decade, while still early in its application, stimulates practitioners to not only identify the environmental influences on individual behaviour but also consider the relationship between these, the reinforcing and balancing feedback loops, the key players, points of leverage and the consequences of change on the system.6, 7 Systems thinking also reminds us that the conditions that influence eating behaviour and diets are dynamic and therefore require monitoring and ongoing evaluation. The toolkit used by dietitians to tackle the environmental conditions that shape and reinforce eating behaviour has had to extend far beyond nutrition education to advocacy, facilitation, intersectoral action, capacity building and community engagement, making the practice of dietetics both challenging and rewarding. This issue of Nutrition & Dietetics explores the theme of nutrition in vulnerable populations including Indigenous populations in Australia and Canada, minority groups in USA, youth in Korea and Australia, elderly populations in aged care facilities or undergoing surgery, school-aged children in Australia and Canada and people living with HIV. New knowledge and insights provide a forum to achieve greater understanding of the issues in addressing health inequities for populations considered vulnerable. Authors look beyond the individual to the conditions in which their study participants were born, grow, live, work and age. Anaemia in pregnancy is common worldwide with particularly high prevalence in vulnerable populations.8 It can lead to detrimental outcomes for both the mother and child.9 In Australia, Aboriginal and Torres Strait Islander people are almost twice as likely as non-Indigenous people to be at risk of anaemia, and 1 in 10 Aboriginal and Torres Strait Islander women are at-risk.10 Leonard et al.,11 in this issue of Nutrition & Dietetics, examine anaemia in pregnancy among Aboriginal and Torres Strait Islander women of Far North Queensland (QLD). Through combining available datasets, authors reveal an alarming rate of over half the mothers of Far North Queensland having anaemia in pregnancy; a rate similar to that reported for two remote Northern Territory communities. Six of every 100 Australian births are to an Aboriginal or Torres Strait Islander parent.12 Authors look beyond individual behaviour to recommend ‘policy commitment to improving food security, promoting good nutrition and providing targeted iron supplementation and/or fortification for pregnant women’. To provide optimal health care and close the health gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians, a culturally competent health workforce is essential. Building a culturally competent workforce starts at university level. Svarc et al.13 consider the preparation of dietetics graduates for practice with Aboriginal communities. The authors challenge dietetic curriculum leads to incorporate elements of placement experiences with Aboriginal and Torres Strait Islander populations into curriculum content where placement experiences may not be feasible, an exciting area of research and practice. The dietary importance of the extremely nutritious native foods, most familiar to many Aboriginal and Torres Strait Islander people, has largely been overlooked in health prevention strategies and policy.14 Indigenous Australians have an intricate relationship with and detailed knowledge of these foods. Fyfe et al.15 in this issue of Nutrition & Dietetics, reveal the superb nutritional properties of the ‘Green Plum’, the fruit of a native plant that grows prolifically in the sub-tropical woodlands of northern Australia and is consumed by Indigenous peoples of the Northern Territory and Western Australia. The plant has medicinal properties, reminding me of a time when I experienced tooth-ache when staying in a north east Arnhem community, Northern Territory, and senior women shared their knowledge of the analgesic properties of the ‘munydjutj’ (Green Plum) plant. Opportunity for Indigenous Australians to establish wild harvesting and processing enterprises of such native foods in a way that is culturally appropriate and in the control of Aboriginal and Torres Strait Islander peoples, could contribute importantly to improved livelihoods, food security, nutrition and health. Food security exists when ‘all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food, which meets their dietary needs and food preferences for an active and healthy life’.16 Australia is a food secure country, however, food is not equitably distributed. Twenty-two per cent of Aboriginal and Torres Strait Islander peoples, 16% of Australians living in rental accommodation and 11% of Australians with no employment were living in a household that in the previous 12 months had run out of food and had not been able to afford to buy more.17 Many of the people living with HIV in Australia are members of these population groups but there is little known about the prevalence of food insecurity among people living with HIV.18 The article by Langton et al.18 provides an up to date report of food insecurity among this population group. Persistent racial/ethnic differences in health are a major public health problem.19 The physical, social and socio-economic characteristics of our neighbourhoods can impact our health and may partly explain health disparities.20 Vaccaro et al.21 show differences in unhealthy food consumption by race/ethnicity among Mexican American, other Hispanic, non-Hispanic black and non-Hispanic white adults using data from the US National Health and Nutrition Survey. The neighbourhood food environment likely contributes to these differences. In USA, there is evidence that lower income communities and those with higher percentages of ethnic minorities have both greater access to outlets that sell unhealthy food and lower access to those selling healthy food.22, 23 More research is needed to guide effective policy and policy implementation and evaluation in this complex area of environments, eating behaviour, health and equity, where there are powerful interests at play. School breakfast programs offer a public health approach to addressing food insecurity for children that minimises stigma when made available for all. Deavin et al.24 explore the acceptability and perceived benefits of the ‘Breaking Bread, Breaking Barriers’ program in a public primary school in the Illawarra region of New South Wales, Australia, that provided a free breakfast to school-aged children using donated food. Operating over two terms, the program saved an impressive 14.4 t of food from landfill through conversion into 44 000 meals. It will be useful to consider how this model can be applied more broadly and with the provision of only healthy donor food. There has been less research among adolescent and young adult populations than that of adults and children.25 Adolescents and young adults are establishing behaviours that can track in to adult life and are at a stage when they are very receptive to their environment and can readily adopt high risk behaviours. Park et al.25 investigate the association between dietary habits and perceived mental and physical health among a representative sample of Korean youths with data from an online self-report survey conducted by the Korea Centres for Disease Control and Prevention. The study protocol of Lombard et al.26 details an innovative 4-phase study that seeks to understand how young adults use social media in relation to their health issues. This cross-disciplinary team is combining the tools and techniques of social marketing with social media platforms to reach young adults including Aboriginal Australians, to motivate them to engage in healthy eating behaviours to reduce the risk of obesity. Our elderly are our national treasures and yet their needs can be too easily overlooked. By 2050, up to 9% of the Australian population will be aged 85 years or more.27 This issue highlights the importance of providing adequate, enjoyable and culturally appropriate nutrition for older people in aged care facilities. Farrer et al.27 forewarn of how generational differences in the health-care needs of our ageing population will present new challenges to our health-care services. We need public health approaches that help create physical and social environments conducive to healthy eating to have the greatest potential to improve the health of our nations.28 Over the years, we have come to understand that certain populations are at risk of disparate health outcomes because of inequities in the distribution of wealth and power and/or the prejudices and intolerances that exist within society. In tackling issues upstream we need to harness the power, know-how and capacity of those considered the most vulnerable in designing and implementing policy. The author received no funding to write this Editorial. The author has no conflict of interest to report. JB is the sole author of this manuscript.

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