How do we make the easiest food choice the healthiest?

Gretchen Miller: Hello there. Welcome to Prevention Works, a podcast all about preventing chronic disease. I’m Gretchen Miller and I’m the host of a series of conversations with some of the nation’s top public health researchers, around the work of The Australian Prevention Partnership Centre. The Prevention Centre brings together policy makers and researchers to find new ways of preventing Australia’s greatest health challenge: lifestyle-related chronic illness. Now, if you’ve travelled overseas at all you’ll know Australians have some of the most delicious and most varied fresh produce in the world. So why is it we reach for the pre-made pizza instead of the bright array of fresh, unprocessed food in our supermarkets? And when I say “we”, that’s 96 percent of Australians who don’t have a healthy diet. The likelihood is that includes me and you. Today’s interview is with Professor Amanda Lee. She’s a Brisbane-based Senior Adviser with the Prevention Centre and for over 35 years nutrition’s been her expertise. Obesity, chronic disease prevention and Indigenous health have been her focus, and her current research with the Prevention Centre is all about the cost of eating healthily. To the team’s surprise, it is cheaper. And yet we still spend the majority of our food dollar on the bad stuff. Thanks for your time today Amanda. Let’s go straight to the heart of the matter and the heart of the country: the APY lands in central Australia, where the community itself has taken part in a 30-year effort to change its diet. Tell me what happened there.

Amanda Lee: Well a lot of people on the APY lands came in from the bush, so were hunter-gatherers until about the 60s and the 70s. So as hunter-gatherers their lifestyle was tough but they were very fit and healthy and had a very diverse and healthy diet. But coming in and settling down in small communities on country meant that they were suddenly exposed to Western diet. So all the problems with excess sugar, salt, saturated fat that had never been a problem with food distribution systems and traditional foods. So people started getting sick very quickly, there was problems with heart disease and diabetes that manifested very quickly within the first 10 years of contact. So for the last 30 years people have been really trying to improve the food supply that they get from Alice Springs and from Adelaide and to eat healthy. They’re trying to eat store foods centermost like bush foods.

Gretchen Miller: We’ll get to the detail of how they do that in a moment, but if you were to walk into any one of those communities, and I know every one is different, but they do share some things in common. For example, I wonder how many supermarkets you might have to choose from in a community, what sort of choice you have?

Amanda Lee: Well you don’t have any choice. There’s one store, so we’ve got a monopoly situation in most communities, and in that store you probably get about 400 items. But in our supermarkets there’s you know over 30,000. So, choice is very restricted and there’s a monopoly.

Gretchen Miller: So, if you and I were walking down the street say 30 years ago and we went inside one of these stores, what might we find by way of food for dinner tonight?

Amanda Lee: Thirty years ago you would have seen a tin shed and it might have had a drum of flour and some sugar and some bully beef and very few fruit and vegetables, so you know things were very much a traditional colonial diet if you like, all the foods that were easy to transport and had long shelf-life were the things that were provided. So, from there we got funding for communities and there was fridges and freezers put in. So that meant that the variety of foods could be expanded. Unfortunately, all we’ve seen in the last 30 years despite this concerted effort and incredible work is that the proportion of junk food and drinks in the communities has increased. So things like sugary drinks are now you know very predominant, things like convenience products such as pies that would be heated in microwave or pizzas in microwave. Very popular takeaway food outlets are growing. So there’s actually more pressure on people to eat the unhealthy items. There’s been the advent of television. So the kids are subject to all those ads about junk food and are demanding more lollies and sweets. So, it’s become harder for the community to exert their right for healthy foods.

Gretchen Miller: This is the Australian Prevention Partnership Centre’s podcast, Prevention Works. And honestly, the story for all of us isn’t that great. The most recent dietary survey of 2011 to 13 showed that the broader Australian community gets 35 per cent of its energy from junk food and drinks now, and for the Indigenous and Torres Strait Islander communities it’s 41 per cent, the same as all Australian kids. 41 per cent.

Amanda Lee: In broader Australia too, we just see the same thing reflected. These communities, because they’re smaller and you can control for more variables, they tell a clearer story about the worsening of our diet through broader Australia.

Gretchen Miller: Amanda, you’ve been doing this work for some decades. Why do you care? What brought you here?

Amanda Lee: Look, my first job actually was at Mildura on the Murray, and I was working as a dietitian in the hospital there, and very quickly we built up an enormous referral base so that I was working seven days a week seeing people as outpatients, and the hospital decreed that I shouldn’t see people that came from over the Murray in NSW so we could control services. And they were predominantly Aboriginal people that came from Namatjira Avenue in Coomealla over the other side of the Murray River, and they were just denied a service. And they were the people that were sickest, that had more diabetes, more heart disease, more malnutrition amongst their kids, and I was not able to provide that service into NSW. And it really struck me that our health system is inequitable, and in Australia these days we know that people that are most at risk are those that are most vulnerable socioeconomically, and the most horrific diet-related health statistics occur amongst Aboriginal and Torres Strait Islander people. They suffer the highest rates of diet-related disease. I mean the big problem we have in nutrition is that the foods in our society that are most available and affordable and accessible and in our face every time we go shopping is the chocolates on special and the soft drinks on special, but the foods that are most advertised are the ones that are no good for our health. So we’ve really got to change our food environment so that the healthy choices are the easy choices, and I learnt that out bush and I can see how it’s really relevant to broader society.

Gretchen Miller: You’re listening to Prevention Works. I’m Gretchen Miller talking with nutritionist Amanda Lee. And stay with us because we’ll find out where to find the good stuff and why eating healthy has surprised everyone, including the researchers, by being cheaper than eating junk. It’s interesting actually, reflecting on my local shop, when I think about it when I go in and I struggle like anybody to pick not the chocolate and the chips but you know the nice snack and I do recall that in fact raspberries and berries are prominently on display the minute you walk in. Now, as you walk to the teller that’s where all the chocolates are. However, it just goes to show that if the good stuff is there in front of you, you will go, okay, there is an option that will make me happy but not make me unhappy after I’ve eaten the chocolate bar.=

Amanda Lee: Yes, I think it’s fascinating. People are not really aware of the science and the research that goes into the layout of shops. So it’s no surprise that the things that appeal to you are the things that are front and centre on your way into a store. The interesting things is supermarkets have been associated with both improved health outcomes in communities but also negative health outcomes because it depends on who’s buying what in the supermarket. So unfortunately in lower income areas we see more people shopping in the middle of those supermarket aisles where you have snack foods, soft drinks et cetera. The secret is to only really buy foods from around the perimeter of the supermarket, where you’ve got dairy products, you’ve got meats, lean meats, you’ve got alternatives like all your tofu.

Gretchen Miller: Bread, milk, yogurt…

Amanda Lee: You’ve got bread, milk, yogurt, fruit and vegetables. Just don’t go in the middle aisles and ignore what’s on the ends, and they can be really useful sources of healthy food.

Gretchen Miller: We have been talking about tiny remote communities with around you know 300 people perhaps and a whole raft of extra challenges. But it is interesting, and you’ve been doing this in your work, you can expand the implications of what went on in the APY lands out to the broader Australian community. From remote settlements to small towns and right up to the cities. What commonalities have you found?

Amanda Lee: So more recently we’ve been looking at unpacking some of those drivers for food choice so the one that I’ve been closely investigating is the affordability of healthy food. So we see the same factors at play there. The presumption is that the unhealthy foods are the cheapest options, but when you actually cost what Australians say they’re currently eating – so our current diet – and compare that with the recommended diet from the NHMRC Dietary Guidelines and cost the diets, we were really surprised to find in both areas that a healthy diet can actually be cheaper than what people are currently consuming. You see advertisements on TV for a hamburger and chips with that and it looks like it’s quite, very, very, very cheap, but to feed a whole family you have to buy multiple units of those and that can add up to be a lot more than cooking a very quick, easy meal based on a meat, chicken, alternatives or vegetables like a stir fry. You know, you can cook a family meal quite cheaply. So we were really surprised to find that a healthy diet can be more affordable when you look at the total diet. We were also really surprised to find that when you break down what Australians in city areas are spending our money on, on average a family of two adults and two children spends 58 percent of the food dollar on junk, and it just seemed unbelievable. And in fact we had trouble publishing the paper that documented all this, even though it was very, very technically detailed and quite robust methodologically, we couldn’t get it published because editors kept saying no that’s nonsense. I was really delighted when the Australian Bureau of Statistics analysed consumer price index of food by dietary groups consistent with the Dietary Guidelines, and they got a figure of 58.2 per cent of the food budget is spent on junk food and drinks. Junk foods will provide profit for shareholders in those food companies, but the external costs of those junk foods being such a dominant part of our food system increasing diet-related disease. We’ve got an epidemic of obesity where it’s become normal for Australian adults to be obese. Sixty-five percent of us are overweight or obese, 25 percent of our children. That goes on to lead to huge risks for diabetes. We’ve got an epidemic of diabetes, it’s increasing exponentially. Heart disease is a problem. We’ve only had improvements in heart disease because people are getting to hospital quicker, but most people would be surprised to know that almost 30 percent of all cancers in Australia are caused by poor diet. So you think of the cost to treat those conditions. In Queensland alone, we need to build 200 hospital beds every year just to cope with the excess burden of diet-related diseases.

Gretchen Miller: So what you’re talking about is that the cost isn’t just personal, it applies to the whole society because it reflects therefore in the tax we have to pay to keep our health system running.

Amanda Lee: That’s right. That’s right. Broader society is paying for poor diet and it’s not really sustainable. What’s really interesting is that much of the evidence we’re getting about what we need to do to improve diets is coming from low- and middle-income countries such as Mexico, Chile, Thailand, Vietnam, because in those countries there’s an understanding that they cannot afford to triple bypass their way out of these health problems that are related to diet. They can’t just keep putting in more hospital beds. They’ve got to do something to improve the policy environment so that it’s easier for people to choose healthy options. The other thing that Australia does very well, which we really need to retain, is having that GST exemption on basic healthy foods. So one of the reasons why in Australia healthy diets can be 15 percent less expensive than our current diet is because of that exemption. The last thing we want to do is to see goods and services tax added to basic healthy foods. If we do that healthy diets are going to become unaffordable for the poorest groups in our community.

Gretchen Miller: Is there a country which does have GST on basic healthy foods?

Amanda Lee: Most countries. Australia’s almost unique.

Gretchen Miller: What have you seen happen in those countries where that tax has been placed on that kind of food?

Amanda Lee: Okay, well we’ve used the methods that we’ve developed which is called Healthy Diets ASAP, Australian Standardised Affordability and Pricing methods, we’ve used those in New Zealand where they have a GST on basic healthy food and the costs of healthy and current diets in New Zealand was much closer. So we’ve got more reason in Australia to choose healthier diets.

Gretchen Miller: There’s an example right across the ditch.

Amanda Lee: This is one thing that Australia is definitely doing better than the Kiwis on.

Gretchen Miller: And it’s interesting too of course because you know we’re very similar in terms of our socioeconomic structure. Now before a listener thinks you know when they listen to that statistic of 58 percent of the food budget is spent on junk food, that that’s not me, I eat really well or I eat moderately well, never mind I had a takeaway four nights in a row last week, not counting that. Personally I’m pretty good. This doesn’t apply to me. That’s actually not the case. Can you talk about how many of us follow the dietary guidelines that are available if we go looking for them? How many?

Amanda Lee: Well less than 1 percent of us actually eat according to the evidence base of the Australian Dietary Guidelines. So in the National Nutrition Survey for example…

Gretchen Miller: So 1 percent. Hang on, 1 percent.

Amanda Lee: Less than 1 percent.

Gretchen Miller: So less than 1 percent. So the chances that I, you know, as a reasonably conscious, trying to eat healthily person are in that 1 percent is really low. Even you, even I, even the folk in Canberra, the people around us, none of us match up. None of us are good enough.

Amanda Lee: No, but some diets are better than others. So what we know is that there’s a very strong social gradient to the quality of diets in Australia, as there is globally. So people that are eating the most different from dietary guidelines are low socioeconomic groups: people living in rural and remote areas. The most challenging diets we’ve been talking about are for Aboriginal and Torres Strait Islander people in those areas, and then we get that gradient so that people that have had most privilege, that are most highly educated, that have most disposable income, much more chance that they’re going to be in that 1 percent. But if they’re not, their diets aren’t going to be too bad. So we’re talking about huge extremes of diet. You see that social gradient with overweight and obesity too, although there’s a little bit of a dip up in high income groups because some people in those areas tend to be high in overweight and obesity too.

Gretchen Miller: But I mean to get in that 1 percent or even close to it, or the 4 percent or the 5 or 10 percent, what are the components to eating well?

Amanda Lee: So there’s two major components. The first is eating enough of the basic healthy foods that evidence shows, we’ve got strong scientific evidence that they protect our body and stop the advent of chronic diseases. The second thing is not eating too much of junk that adds nothing to the diet and actually displaces those healthy foods and provides excess added sugar and energy to the diets.

Gretchen Miller: So we’re replacing the good stuff with the bad stuff.

Amanda Lee: Yeah, what the modelling for the Dietary Guidelines showed, that when you try and fit all the foods we need for health into our diet, and we’ve got very sedentary lifestyles at the moment, we’re not getting as much physical activity as we need for health, so we can’t eat a lot of energy. So when you try and fit enough of the healthy foods in the diet there’s just no room for most Australians for any junk food at all. And yet on average we’re having five serves a day.

Gretchen Miller: Of junk food?

Amanda Lee: Of junk food. So junk food’s things like sugary drinks, alcohol, most people wouldn’t realise, commercially prepared cakes, biscuits, pies…

Gretchen Miller: As you said, it was quite controversial for you to come out with a 58 percent statistic for the amount of our food shopping that is discretionary or junk. Why do we think though that this is better value? And how did you prove that it actually isn’t?

Amanda Lee: So we constructed an average family of an adult man, adult woman and two children, and we costed what they say they’re eating on average and developed a basket of foods that we went into the supermarket and collected the price for. We’ve done that now in Sydney and Canberra and Brisbane and we had the same price. We look at different socioeconomic areas. We collect the prices in all the supermarkets of randomly selected areas. Then we compare that with what it would cost people in those communities and in those shops to spend if they bought a basic healthy diet. So similar items, just more of the fruit and vegetables that they’re eating because Australians are eating less than half the fruit and vegetables that they would eat, so more fruit and vegetables but less of the junk foods. When you change those proportions to be consistent with the Dietary Guidelines, it’s about 15 percent less to buy healthy diets than what Australians are currently consuming.

Gretchen Miller: So now you as a researcher know that a healthy diet isn’t more expensive, it’s actually considerably cheaper. How do you get the message out there? I mean sometimes I imagine it would be easier to go okay I’ll just buy the pizza and put it in the oven. We do have to learn to cook, don’t we?

Amanda Lee: The convenience of saving time is really sold to us as being important. I think it’s really critical to unpack what we’re actually sacrificing when we go for that convenience. The other thing is that you know as I keep trying to emphasise, there’s a really strong social gradient here. I remember the first patient that I had as a dietitian and I was talking to her. She was overweight, her two children were overweight, she was a single mother and it was very clear to me that one of the things she could do is just cut back down. She was buying two litres of cola every day for her boys and herself. So the easy thing from my middle class perspective was well just don’t buy that, maybe buy diet product or drink water. And she got really angry with me. It was such an eye opener for me because she said, “How dare you? How dare you take away the only luxury that I can afford for my boys?” So I think that really started me to think about the reasons why people buy what they buy and, you know, unfortunately health isn’t one of the main reasons.

Gretchen Miller: Well we know the term comfort food, don’t we?

Amanda Lee: Mmm. So as a researcher I can see the questions we need to have answered here but I’m not a social researcher. I’m a quantitative and qualitative researcher and we need to work in partnership with other experts to be able to answer some of these key questions. And that’s what’s so good about the Partnership Centre, The Prevention Partnership Centre, because it brings in different expertise to address all components of the food system. Last year we developed a schema that shows all the things that contribute to healthy and equitable eating. So, we’re going to try to move the population diet but in a way that doesn’t add to the dietary inequities we see throughout the system. And to do that we need to address multiple points and we need good quality research in these multiple points, so we can speculate all we like but we really need to have strong research that will help us answer these things because we know that our presumptions can often be wrong.

Gretchen Miller: Okay so before we go, why is all this important? We do talk a lot, or at least the public conversation is often about personal responsibility when it comes to diet. I mean what could be more personal than what we put in our mouths, but really it’s not the case. Why is it important to care as a community about this?

Amanda Lee: Well firstly it’s not commonly known that poor diet is the number one preventable cause of ill health globally. So we have good data that shows it’s the area where we should really be investing in Australia as well as elsewhere through the world. Secondly, it is fixable. We’ve got good evidence from communities, for example, some work that I did with the community of Minjilang in the 1980s. That community could show that within 12 months they were able to improve the food supply in their community’s store, choose healthier options, we tested their biochemistry and biomedical measures of nutrition, we provided individual feedback so that people knew what they needed to do to improve their diet, and within 12 months that whole community turned their diet around. So we know success is possible. Often with nutrition the assumption is that it’s too complex, it’s too hard, and that’s what the Prevention Centre is set up to do. It’s set up to show that using systems science approaches we can tackle these really complex problems, and the health gains from doing that are enormous in the nutrition field. So it’s so exciting to see this work coming to fruition.

Gretchen Miller: Thank you so much for chatting with me today. It’s been absolutely delightful. We’ve had the dog as company and the cat as company, and you know it’s been really interesting to come to your home and speak about these things, and thanks for your work.

Amanda Lee: Thanks very much Gretchen. Lovely to talk to you too.

Gretchen Miller: Thanks to Professor Amanda Lee on the Prevention Works podcast from The Australian Prevention Partnership Centre, and on their website you’ll find more information into the work we’ve been discussing. If you’d like to hear more, why not tune into our episode with Sumitra Muthayya and her team, as we discuss food insecurity that affects 20 percent of urban Aboriginal populations. That’s one in five Indigenous Australians don’t always know where their next meal is coming from. But they’re working on it. You’ll find all this and more at preventioncentre.org.au. Share us, let your friends and colleagues know. I’m Gretchen Miller. See you next time.