The health and nutrition of young indigenous women in north Queensland – intergenerational implications of poor food quality, obesity, diabetes, tobacco smoking and alcohol use

Maternal Diet Influences Fetal Growth but Not Fetal Kidney Volume in an Australian Indigenous Pregnancy Cohort

Suboptimal nutrition during pregnancy is recognised as a significant modifiable determinant in the development of chronic disease in offspring in later life. The current study aimed: (i) to assess the dietary intakes of pregnant Indigenous Australian women against national recommendations and (ii) to investigate the associations between maternal nutrition during pregnancy and the growth of the offspring, including kidney development in late gestation in the Gomeroi gaaynggal cohort (n = 103). Maternal dietary intake in the third trimester was assessed using the Australian Eating Survey Food Frequency Questionnaire. Estimated fetal weight (EFW) and kidney size were obtained by ultrasound. Birth weight was retrieved from hospital birth records. Of the five key nutrients for optimal reproductive health (folate, iron, calcium, zinc and fibre), the nutrients with the highest percentage of pregnant women achieving the nutrient reference values (NRVs) were zinc (75.7%) and folate (57.3%), whereas iron was the lowest. Only four people achieved all NRVs (folate, iron, calcium, zinc and fibre) important in pregnancy. Sodium and saturated fat intake exceeded recommended levels and diet quality was low, with a median score of 28 out of 73 points. After adjusting for smoking and pre-pregnancy body mass index, only maternal intake of retinol equivalents and the proportion of energy from nutrient-dense or energy-dense, nutrient-poor (EDNP) foods were associated with fetal growth. EFW decreased by 0.13 g and birth weight decreased by 0.24 g for every µg increase in maternal dietary retinol intake. Interestingly, EFW, but not actual birth weight, was positively associated with percentage energy from nutrient dense foods and negatively associated with percentage energy from EDNP foods. Dietary supplement usage was associated with increased birthweight, most significantly iron and folate supplementation. Current dietary intakes of pregnant Australian women from this cohort do not align with national guidelines. Furthermore, current findings show that maternal retinol intake and diet composition during pregnancy can influence fetal growth, but not fetal kidney growth in late gestation. Strategies that aim to support and optimise nutrient intakes of Indigenous pregnant women are urgently needed. Future studies with long-term follow-up of the children in the current cohort to assess renal damage and blood pressure are imperative.

Is there a relationship between personality traits and fruit and vegetable intake among pregnant women?

Previous studies have shown that certain personality traits such as neuroticism and conscientiousness influence dietary choices. Pregnancy is a unique period in a woman’s life during which most women are highly intrinsically and extrinsically motivated to start a diet rich in fruit and vegetables. Yet, an adequate consumption of fruits and vegetables remains a challenge for many women. The present study investigates the relationships between personality traits and fish, dairy, fruit, and vegetable intake. Data was collected from 602 pregnant women and analyzed using descriptive statistics and hierarchical regression analyses in order to examine predictive relationships between the variables of interest. The results demonstrated that high scores in openness to experience, older maternal age, higher income, and educational attainment were positively associated with increased fish, vegetable, and fruit intake. These findings have important implications for interventions that seek to improve eating behaviors of pregnant women, thereby increasing the health of their pregnancies.

Preconception Care in a Remote Aboriginal Community Context: What, When and by Whom?

Preconception care (PCC) is acknowledged as a vital preventive health measure aiming to promote health today and for subsequent generations. We aimed to describe the content and context of PCC delivery in a very remote Australian Aboriginal Community Controlled Health Service setting. A retrospective audit was undertaken to identify what PCC was delivered between 2011 and 2018 to 127 Aboriginal women who had at least one pregnancy during this period. Of 177 confirmed pregnancies, 121 had received PCC prior to the pregnancy. Sexually transmissible infection screening (71%) was the most common care delivered, followed by folic acid prescription (57%) and smoking cessation support (43%). Younger women received PCC less often, particularly screening for modifiable pregnancy risk factors. Rates of prediabetes/diabetes, albuminuria, overweight/obesity and smoking were high amongst those screened (48-60%). PCC was usually patient-initiated and increased significantly over the audit period. Presentation for antenatal care in the first trimester of pregnancy was high at 73%. Opportunities to increase PCC delivery include integration with routine health checks, pregnancy tests and chronic disease programs. PCC programs codesigned with young people are also recommended. All primary care providers should be supported and assisted to provide opportunistic PCC and health promotion.

Folic acid deficiency declined substantially after introduction of the mandatory fortification programme in Queensland, Australia: a secondary health data analysis

OBJECTIVE

To investigate the prevalence of folic acid deficiency in Queensland-wide data of routine laboratory measurements, especially in high-risk sub-populations.

DESIGN

Secondary health data analysis.

SETTING

Analysis of routine folic acid tests conducted by Pathology Queensland (AUSLAB).

PARTICIPANTS

Female and male persons aged 0-117 years with routine folic acid testing between 1 January 2004 and 31 December 2015. If repeat tests on the same person were conducted, only the initial test was analysed (n 291 908).

RESULTS

Overall the prevalence of folic acid deficiency declined from 7·5 % before (2004-2008) to 1·1 % after mandatory folic acid fortification (2010-2015; P < 0·001) reflecting a relative reduction of 85 %. Levels of erythrocyte folate increased significantly from a median (interquartile range) of 820 (580-1180) nmol/l in 2008 before fortification to 1020 (780-1350) nmol/l in 2010 (P < 0·001) after fortification. The prevalence of folic acid deficiency in the Indigenous population (14 792 samples) declined by 93 % (17·4 v. 1·3 %; P < 0·001); and by 84 % in non-Indigenous residents (7·0 v. 1·1 %; P < 0·001). In a logistic regression model the observed decrease of folic acid deficiency between 2008 and 2010 was found independent of gender, age and ethnicity (ORcrude = 0·20; 95 % CI 0·18, 0·23; P < 0·001; ORadjusted = 0·21; 95 % CI 0·18, 0·23; P < 0·001).

CONCLUSIONS

While voluntary folic acid fortification, introduced in 1995, failed especially in high-risk subgroups, the 2009 mandatory folic acid fortification programme coincided with a substantial decrease of folic acid deficiency in the entire population.

Low proportions of folic acid deficiency after introduction of mandatory folic acid fortification in remote areas of northern Queensland, Australia: a secondary health data analysis

Background: Australia implemented mandatory folic acid fortification of bread-making flour in 2009. Objective: To assess the impact of folic acid fortification in remote vs. regional urban areas and Indigenous vs. non-Indigenous populations in northern Queensland. Methods: Routinely collected data on folic acid measurements in remote areas and two regional urban centres in northern Queensland between 2004 and 2015 were analysed (n = 13,929) dichotomously (folic deficient vs. non-deficient). Results: Overall prevalence of folic acid deficiency was 3.2% (235/7282) in urban centres compared with 7.2% (480/6647) in remote areas (p < 0.001), and 9.3% (393/4240) in the Indigenous population compared with 3.2% (273/8451) in the non-Indigenous population (p < 0.001). Prevalence of folic acid deficiency dropped from 12.2% (n = 481) in 2004-2008 to 1.5% (n = 126) in 2010-2015 (p < 0.001). This translates into a relative risk reduction (RRR) of 88%. RRR was 79% (7.2% vs. 1.5%) in urban centres, 91% (17.3% vs. 1.5%) in remote areas, 92% (20.5% vs. 1.6%) in the Indigenous population and 80% (7.4% vs. 1.5%) in the non-Indigenous population (p < 0.001 for all). Conclusions: Substantial declines of folic acid deficiency to low and comparable proportions in former high-risk populations indicate that mandatory folic acid fortification of flour has had a population-wide benefit in northern Queensland.

Changes in exercise capacity and anthropometric measures after Work It Out-a holistic chronic disease self-management program for urban Aboriginal and Torres Strait Islander people

OBJECTIVES

The Work It Out (WIO) program is a holistic chronic disease self-management and rehabilitation program in Queensland that is tailored for urban Aboriginal and Torres Strait Islander people with/at risk of chronic disease. This study aimed to examine the overall changes in participants' exercise capacity and anthropometric measurements and to explore the correlations between these changes.

STUDY DESIGN

Quasi-experimental prepost intervention study.

METHODS

A total of 406 participants self-identified as Aboriginal and Torres Strait Islander people, who had attended one or more cycles of the program from 2014 to 2017, were included. Health information from the last review assessment was compared with that of the initial assessment using paired t-tests. Multivariate regression models were applied to explore the associations between changes in 6-min walk distance (6MWD) and anthropometric measurements.

RESULTS

An increase in 6MWD (77 m, 95% confidence interval [CI]: 65, 90), as well as small reductions in waist circumference (WC) (-1.79 cm, 95% CI: -2.76 to -0.82) and hip circumference (-1.11 cm, 95% CI: -2.13 to -0.08) were identified. Statistically significant reductions were observed across all anthropometric measures in the respective highest tertiles (body mass index: -0.71, 95% CI: -1.35 to -0.07; weight: -2.59 kg, 95% CI: -4.84 to -0.34; WC: -5.09 cm, 95% CI: -6.99 to -3.20; waist to hip ratio: -0.033, 95% CI: -0.047 to -0.02). The increments of 6MWD in returning participants (92 m, 95% CI: 75 to 109) was found to be greater than those in one-off participants (59 m, 95% CI: 40-78). In particular, the percentage of 6MWD change from baseline was significantly correlated to the percentage of WC change after adjusting for age, gender, the number of pre-existing chronic conditions, and the number of cycles attended (coefficient: -1.33, 95% CI: -2.42 to -0.24).

CONCLUSION

Significant improvement in functional exercise capacity and modest changes in anthropometric measurements were identified in WIO participants. WC change could be used as an indicator of the change of participants' six-minute walk distance. Findings may be useful for promoting and guiding similar health programs for improving chronic disease management in Australian Indigenous communities.

Anaemia in early childhood among Aboriginal and Torres Strait Islander children of Far North Queensland: a retrospective cohort study

OBJECTIVE

Early childhood anaemia affects health and neurodevelopment. This study describes anaemia among Aboriginal and Torres Strait Islander children of Far North Queensland.

METHODS

This retrospective cohort study used health information for children born between 2006 and 2010 and their mothers. We describe the incidence of early childhood anaemia and compare characteristics of children and mothers where the child had anaemia with characteristics of children and mothers where the child did not have anaemia using bivariate and multivariable analysis, by complete case (CC) and with multiple imputed (MI) data.

RESULTS

Among these (n=708) Aboriginal and Torres Strait Islander children of Far North Queensland, 61.3% (95%CI 57.7%, 64.9%) became anaemic between the ages of six and 23 months. Multivariable analysis showed a lower incidence of anaemia among girls (CC/MI p<0.001) and among children of Torres Strait Islander mothers or both Aboriginal and Torres Strait Islander mothers (CC/MI p<0.001) compared to children of Aboriginal mothers. A higher incidence of anaemia was seen among children of mothers with parity three or more (CC/MI p<0.001); children born by caesarean section (CC/MI p<0.001); and children with rapid early growth (CC/MI p<0.001).

CONCLUSION

Early childhood anaemia is common among Aboriginal and Torres Strait Islander children of Far North Queensland. Poor nutrition, particularly iron deficiency, and frequent infections are likely causes. Implications for public health: Prevention of early childhood anaemia in 'Close the Gap' initiatives would benefit the Aboriginal and Torres Strait Islander children of Far North Queensland - and elsewhere in northern Australia.

Diabetes and smoking as predictors of cancer in Indigenous adults from rural and remote communities of North Queensland - A 15-year follow up study

Indigenous Australians generally have a poor health status and an elevated cancer mortality that has increased in recent decades. A cohort of 2,273 Aboriginal and Torres Strait Islander (TSI) adults (18+ years) from 26 remote communities in far North Queensland, who were initially free of cancer, were followed-up for an average of 15 years. The associations of baseline anthropometric, biochemical and behavioural factors with cancer incidence were investigated using competing risk survival analysis. The age-standardised incidence (all cancers) was 5.2 cases/1,000 person-years (pys) (95% CI 4.1-6.6). Liver/bile duct and lung were the most common cancer sites. Overall cancer incidence was significantly higher in TSIs than Aboriginal people. The baseline prevalence of diabetes was 15.6% in Aboriginal and 25.6% in TSI people. The smoking rate of 59.8% for Aboriginal people was higher than the rate of 45.2% for TSIs. At follow-up, the adjusted sub hazard ratios (SHRs) of diabetes for all cancers combined were 1.8 (95% CI, 1.3-2.6), and for digestive system cancers, 2.3 (95% CI, 1.2-4.4). Smokers had a 60% higher risk (SHR 1.6, 95% CI: 1.1-2.0) for all cancers combined and a fourfold risk (SHR 3.7, 95% CI 1.7-8.0) for lung cancers when compared to non-smokers, regardless of age, sex and ethnicity. The most common cancers encountered by this Indigenous cohort and their consequences are potentially preventable in Indigenous Australians by effective management of highly prevalent modifiable risks in primary service settings, screening participation and arranging for good access to treatment services.

Intergenerational and early life influences on the well-being of Australian Aboriginal and Torres Strait Islander children: overview and selected findings from Footprints in Time, the Longitudinal Study of Indigenous Children

Footprints in Time: The Longitudinal Study of Indigenous Children (LSIC) is a national study of 1759 Australian Aboriginal and Torres Strait Islander children living across urban, regional and remote areas of Australia. The study is in its 11th wave of annual data collection, having collected extensive data on topics including birth and early life influences, parental health and well-being, identity, cultural engagement, language use, housing, racism, school engagement and academic achievement, and social and emotional well-being. The current paper reviews a selection of major findings from Footprints in Time relating to the developmental origins of health and disease for Australian Aboriginal and Torres Strait Islander peoples. Opportunities for new researchers to conduct further research utilizing the LSIC data set are also presented.

What do we know about the diets of Aboriginal and Torres Strait Islander peoples in Australia? A systematic literature review

OBJECTIVE

To provide an overview of published research on the dietary intake of Aboriginal and Torres Strait Islander peoples.

METHODS

Peer-reviewed literature from 1990 to October 2016 was searched to identify studies that measured the dietary intake of Australian Aboriginal and Torres Strait Islander populations. Study quality was assessed using a purposely devised quality appraisal tool. Meta-analysis was not possible due to the heterogeneity in dietary intake assessment methods. A narrative synthesis of study findings, where key themes were compared and contrasted was completed.

RESULTS

Twenty-five articles from twenty studies with outcome measures related to dietary intake were included. Dietary intake was assessed by electronic store sales, store turnover method, 24-hour dietary recall, food frequency questionnaire and short questions. Consistent findings were low reported intakes of fruit and vegetables and high intakes of total sugar and energy-dense, nutrient-poor food and beverages.

CONCLUSIONS

While differences between studies and study quality limit the generalisability of the findings, most studies suggest that the diets of Aboriginal and Torres Strait Islander peoples are inadequate. Implications for public health: A more concerted approach to understanding dietary patterns of Aboriginal and Torres Strait Islander peoples is required to inform policy and practice to improve diet and nutrition.

Preconception care for women with type 2 diabetes mellitus: A mixed-methods study of provider knowledge and practice

AIMS

Preconception care may decrease adverse pregnancy outcomes associated with pre-existing diabetes mellitus. Aboriginal Australians are at high risk of type 2 diabetes mellitus (T2DM), with earlier onset. We explored practitioner views on preconception care delivery for women with T2DM in the Northern Territory, where 31% of births are to Aboriginal women.

METHODS

Mixed-methods study including cross-sectional survey of 156 health practitioners and 11 semi-structured interviews.

RESULTS

Practitioners reported low attendance for preconception care however, 51% provided counselling on an opportunistic basis. Rural/remote practitioners were most likely to find counselling feasible. The majority (69%) utilised appropriate guidelines and addressed lifestyle modifications including smoking (81%), weight management (79%), and change medications appropriately such as ceasing ACE inhibitors (69%). Fewer (40%) prescribed the recommended dose of folate (5mg) or felt comfortable recommending delaying pregnancy to achieve optimal preconception glucose control (42%). Themes identified as barriers to care included the complexity of care setting and infrequent preconception consultations. There was a focus on motivation of women to make informed choices about conception, including birth spacing, timing and contraception. Preconception care enablers included cross-cultural communication, a multi-disciplinary care team and strong client-based relationships.

CONCLUSIONS

Health practitioners are keen to provide preconception counselling and reported knowledge of evidence-based guidelines. Improvements are needed in recommending high dose folate and optimising glucose control. Cross-cultural communication and team-based care were reported as fundamental to successful preconception care in women with T2DM. Continued education and policy changes are required to support practitioners in opportunities to enhance pregnancy planning.

Smoking in Pregnancy Among Indigenous Women in High-Income Countries: A Narrative Review

INTRODUCTION

Pregnant women in socioeconomically disadvantaged circumstances, such as Indigenous women, have a high prevalence of smoking. Tobacco smoking is the most significant reversible risk factor for the health of Indigenous pregnant women and their babies.

METHODS

As researchers working in this specialized area, we conducted a narrative review of the literature on smoking among Indigenous pregnant women in the United States, Canada, New Zealand, and Australia. We summarize prevalence and factors influencing tobacco use, interventions, and evidence gaps for tobacco control and smoking cessation. Recommendations are made for future interventions, policy changes, and much-needed research.

RESULTS

Common themes emerging across the four countries reveal opportunities for cross-cultural collaborative studies and trials. These include the social-normative use of tobacco as barriers to quitting in pregnancy and the need for evaluations of interventions at the family and community level. Socioeconomic disparities underscore the importance of enhancing the implementation and reach of strategies to prevent and reduce prenatal tobacco smoking among Indigenous women. Elders and community health care providers as role models for nontobacco use could be explored. Qualitative work is needed to understand the barriers and opportunities, such as cultural strengths supporting quitting tobacco to develop more effective approaches.

CONCLUSIONS

Although a high-priority group, there remains a dearth of research on Indigenous women's smoking in pregnancy. Studies have assessed knowledge and attitudes to smoking in pregnancy, and small feasibility studies and a few empirical trials have been conducted. Recommendations for promising culturally appropriate cessation interventions have been made. Larger trials are warranted.

IMPLICATIONS

Strategies to support quitting among pregnant Indigenous women need to be multifactorial and take account of the social determinants of smoking including historical antecedents, community norms, cultural strengths, and recognition of individual and community needs. Cross-country research collaborations have the potential to leverage funding, share expertise, and strengthen approaches to tackle an important and poorly attended health disparity that has a profound impact on the entire life course for Indigenous peoples.

Gender determinants of smoking practice in Indigenous communities: an exploratory study

Despite the need to urgently reduce smoking rates among Indigenous Australians, in order to close-the-gap in life expectancy, little is known regarding how this can be achieved. This study aimed to explore whether a focus on gender specific determinants of smoking among Indigenous Australians could be identified, thus providing a potentially novel approach to underpin future efforts at intervention. A qualitative research design was employed. Eighty-two participants, comprised of 43 Indigenous women (mean age 32.15, SD, 12.47) and 39 Indigenous men (mean age 34.91, SD, 11.26), participated in one of 12 focus groups held in metropolitan, regional and rural locations in South Australia. Facilitators prompted discussion in response to the question: 'What is it like being a smoker these days?' Two experienced coders assessed data for themes using Attride-Stirling's (2002) method of analysis. Two global themes emerged for men and women. The first theme, 'It's Harder to Smoke Nowadays', encompassed sub-themes capturing changed smoking practices in response to tobacco control strategies implemented in Australia. Sub-themes of 'smoking in secrecy' coupled with an 'awareness of the effects of passive smoking' were identified among women. Among men, sub-themes that depicted tension between 'a desire to be a role model' and 'guilt about smoking' emerged. The second theme, 'Push and Pull Factors', identified a range of gender specific determinants of smoking. While similar reasons for smoking ('pull factors') were identified in men and women (e.g. addiction, boredom, stress, pleasure, mood stabiliser), different 'push factors' (reasons for not wanting to smoke) emerged. For men, sport, fitness and children were identified as reasons for not wanting to smoke, whereas women identified factors such as respect for non-smokers, and body image concerns. The current findings suggest that there may be fundamental differences in the determinants of smoking (pull factors) as well as reasons for wanting to quit (push factors) between Indigenous men and women. A focus on interventions that target gender specific determinants, or motivators of smoking, offers a novel, and potentially efficacious approach to reduce smoking rates among Indigenous Australians.

Drivers of maternity care in high-income countries: can health systems support woman-centred care?

In high-income countries, medical interventions to address the known risks associated with pregnancy and birth have been largely successful and have resulted in very low levels of maternal and neonatal mortality. In this Series paper, we present the main care delivery models, with case studies of the USA and Sweden, and examine the main drivers of these models. Although nearly all births are attended by a skilled birth attendant and are in an institution, practice, cadre, facility size, and place of birth vary widely; for example, births occur in homes, birth centres, midwifery-led birthing units in hospitals, and in high intervention hospital birthing facilities. Not all care is evidenced-based, and some care provision may be harmful. Fear prevails among subsets of women and providers. In some settings, medical liability costs are enormous, human resource shortages are common, and costs of providing care can be very high. New challenges linked to alteration of epidemiology, such as obesity and older age during pregnancy, are also present. Data are often not readily available to inform policy and practice in a timely way and surveillance requires greater attention and investment. Outcomes are not equitable, and disadvantaged segments of the population face access issues and substantially elevated risks. At the same time, examples of excellence and progress exist, from clinical interventions to models of care and practice. Labourists (who provide care for all the facility's women for labour and delivery) are discussed as a potential solution. Quality and safety factors are informed by women's experiences, as well as medical evidence. Progress requires the ability to normalise birth for most women, with integrated services available if complications develop. We also discuss mechanisms to improve quality of care and highlight areas where research can address knowledge gaps with potential for impact. Evaluation of models that provide woman-centred care and the best outcomes without high costs is required to provide an impetus for change.

Improving the provision of pregnancy care for Aboriginal and Torres Strait Islander women: a continuous quality improvement initiative

Background

Australian Aboriginal and Torres Strait Islander (Indigenous) women are at greater risk of adverse pregnancy outcomes than non-Indigenous women. Pregnancy care has a key role in identifying and addressing modifiable risk factors that contribute to adverse outcomes. We investigated whether participation in a continuous quality improvement (CQI) initiative was associated with increases in provision of recommended pregnancy care by primary health care centers (PHCs) in predominantly Indigenous communities, and whether provision of care was associated with organizational systems or characteristics.

Methods

Longitudinal analysis of 2220 pregnancy care records from 50 PHCs involved in up to four cycles of CQI in Australia between 2007 and 2012. Linear and logistic regression analyses investigated associations between documented provision of pregnancy care and each CQI cycle, and self-ratings of organizational systems. Main outcome measures included screening and counselling for lifestyle-related risk factors.

Results

Women attending PHCs after ≥1 CQI cycles were more likely to receive each pregnancy care measure than women attending before PHCs had completed one cycle e.g. screening for cigarette use: baseline = 73 % (reference), cycle one = 90 % [odds ratio (OR):3.0, 95 % confidence interval (CI):2.2-4.1], two = 91 % (OR:5.1, 95 % CI:3.3-7.8), three = 93 % (OR:6.3, 95 % CI:3.1-13), four = 95 % (OR:11, 95 % CI:4.3-29). Greater self-ratings of overall organizational systems were significantly associated with greater screening for alcohol use (β = 6.8, 95 % CI:0.25-13), nutrition counselling (β = 8.3, 95 % CI:3.1-13), and folate prescription (β = 7.9, 95 % CI:2.6-13).

Conclusion

Participation in a CQI initiative by PHCs in Indigenous communities is associated with greater provision of pregnancy care regarding lifestyle-related risk factors. More broadly, these findings support incorporation of CQI activities addressing systems level issues into primary care settings to improve the quality of pregnancy care.

Smoking, poor nutrition, and sexually transmitted infections associated with pelvic inflammatory disease in remote North Queensland Indigenous communities, 1998-2005

Background

Indigenous women in remote North Queensland have a high prevalence of unhealthy lifestyle behaviors and associated health conditions such as sexual transmitted infections (STI). The association of severe pelvic inflammatory disease (PID) with these factors has not been studied. The purpose of this study is to associate the factors with severe PID, as indicated by hospitalization in a high risk population in North Queensland Indigenous communities.

Methods

A cross-sectional association of 1445 Indigenous women using linked hospital separation and survey data during 1998–2005.

Results

The mean age of participating women was 37.4 years, 60% were of Aboriginal and 40% were Torres Strait Island (TSI) people. More than half of them (52.5%) were smokers, 9.3% had chlamydia and 2.6% had gonorrhoea with the overall prevalence of STI among those less than 25 years of age being 23.9%. Among the 47 participants diagnosed with PID in the study period, 42.5% were under 25 years and 95.7% (45 cases) were under 55 years (OR 2.5, 95% CI 1.2-4.1 among women younger than 25 compared to those 25 years and over). PID was strongly associated with smoking (OR 3.1, 95% CI 1.4-9.2) independent of age, ethnicity, STI and folate status. Low red cell folate increased PID hospitalization by 4 times (95% CI 1.5-13.2 of lowest quartile compared to the highest quartile) regardless of age. Having a STI significantly increased the likelihood of severe PID by 2.2 times (95% CI: 1.03-4.5) in Indigenous women younger than 45 years, independent of smoking and folate level. The risk of PID hospitalization was higher for gonorrheal infections (OR 3.2, 955 CI 1.1-9.6) compared to chlamydial infections (OR 1.5 95% CI 0.7-3.5).

Conclusions

Young Indigenous women in North Queensland communities are at very high risk for STI and PID. Smoking, low folate, and STI are clustered, and are associated with PID hospitalizations. Much of this can be prevented with improved nutrition and access to preventive services, especially tobacco control, regular STI screening and treatment, as well as more investment in sexual health education and awareness.

Electronic supplementary material

The online version of this article (doi:10.1186/s12905-015-0188-z) contains supplementary material, which is available to authorized users.

Placental inflammation is associated with rural and remote residence in the Northern Territory, Australia: a cross-sectional study

Background

The Northern Territory has the highest rates of perinatal morbidity and mortality in Australia. Placental histopathology has not been studied in this high-risk group of women.

Methods

This is the first study to detail the placental pathology in Indigenous women and to compare the findings with non-Indigenous women in the Northern Territory. There were a total of 269 deliveries during a three-month period from the 27^th of June to the 27^th of August 2009. Seventy-one (71%) percent of all placentas were examined macroscopically, sectioned then reviewed by a Perinatal Pathologist, blinded to the maternal history and outcomes.

Results

Indigenous women were found to have higher rates of histologically confirmed chorioamnionitis and or a fetal inflammatory response compared with non-Indigenous women (46% versus 26%; OR 2.4, 95% CI 1.3-4.5). In contrast, non-Indigenous women were twice as likely to show vascular related pathology (31% versus 14%; OR 2.77, 95% CI 1.3-5.9). Indigenous women had significantly higher rates of potentially modifiable risk factors for placental inflammation including genitourinary infections, anaemia and smoking. After adjusting for confounders, histological chorioamnionitis and fetal inflammatory response was significantly associated with rural or remote residence (Adjusted OR 2.5, 95% CI 1.08 – 5.8).

Conclusion

This study has revealed a complex aetiology underlying a high prevalence of placental inflammation in the Northern Territory. Placental inflammation is associated with rural and remote residence, which may represent greater impact of systemic disadvantage, particularly affecting Indigenous women in the Northern Territory.

The worldwide epidemic of female obesity

The rapidly rising number of individuals who are overweight and obese has been called a worldwide epidemic of obesity with >35% of adults today considered to be overweight or obese. Women are more likely to be overweight and obese than their male counterparts, which has far-reaching effects on reproductive health and specifically pregnancy, with obese women facing an increased risk of gestational diabetes, preeclampsia, operative delivery, fetal macrosomia, and neonatal morbidity. The etiology of obesity is highly complex encompassing genetic, environmental, physiologic, cultural, political, and socioeconomic factors, making it challenging to develop effective interventions on both a local and global scale. This article describes the extent and the cost of the obesity epidemic, which, although historically seen as a disease of high-income countries, is now clearly a global epidemic that impacts low- and middle-income countries and indigenous groups who bear an ever-increasing burden of this disease.

Maternal health issues and cardio-metabolic outcomes in the offspring: a focus on Indigenous populations

Non-communicable diseases (NCDs) including diabetes, obesity and cardiovascular disease are the leading causes of death worldwide. Indigenous populations are disproportionally affected. In an effort to halt the increasing disease burden, the mechanisms underlying the increasing rate of NCDs are an important area of study. Recent evidence has focused on the perinatal period as an influential period impacting the future cardio-metabolic health of the offspring. This concept has been defined as metabolic foetal programming and supports the importance of the developmental origins of health and disease in research and clinical practice, specifically in prevention efforts to protect future generations from NCDs. An understanding of the underlying mechanisms involved is not clear as of yet. However, an understanding of these mechanisms is imperative in order to plan effective intervention strategies. As much of the discussion below is gleaned from large epidemiological studies and animal studies, further research with prospective cohorts is necessary.

Diabetes in young people in the Top End of the Northern Territory

AIM

There is an increasing prevalence and burden of diabetes in young people, particularly Indigenous Australians. There have been no previous reports of the prevalence or burden of diabetes in young people in the Top End of the Northern Territory, a region of many risk factors for diabetes.

METHODS

This is a retrospective study of cases of diabetes in children and adults aged less than 25 years who were seen at Royal Darwin Hospital as inpatients or outpatients between 2007 and 2011.

RESULTS

From a population base of approximately 75 000 young people living north of Tenant Creek, there were 70 young people with type 1 diabetes (12 Aboriginal and/or Torres Strait Islander Australians) and 37 young people with type 2 diabetes (31 Aboriginal or Torres Strait Islander Australians). The median body mass index of those with type 2 diabetes was 28 kg/m(2) , and only 29% had a body mass index >30 kg/m(2) . Overall, glycaemic control was poor.

CONCLUSIONS

Rates of diabetes in young people in the Top End appear high. Case ascertainment and data collection were difficult for this study, highlighting the need for better database and systems for diabetes management.

Stages of change, smoking behaviour and readiness to quit in a large sample of indigenous Australians living in eight remote north Queensland communities

Tobacco smoking is a major health issue for Indigenous Australians, however there are few interventions with demonstrated efficacy in this population. The Transtheoretical Model may provide a useful framework for describing smoking behaviour and assessing readiness to quit, with the aim of developing better interventions. Interviews were conducted with 593 Indigenous Australians in eight rural and remote communities in north Queensland, to examine stages of change and smoking behaviour. Among current smokers, 39.6% and 43.4% were in Precontemplation and Contemplation stages respectively. A further 13.9% were making preparations to quit (Preparation) whilst only 3.2% said they were actively trying to quit (Action). When analysed by stage of change, the pattern of smoking-related behaviours conformed to the results of past research using the model. Importantly however, distribution of individuals across the stages opposes those observed in investigations of smoking behaviour in non-Indigenous Australian populations. The Transtheoretical Model can be used to meaningfully classify Indigenous smokers in remote north Queensland according to stages along the behaviour change continuum. Importantly, in this large sample across eight communities, most Indigenous smokers were not making preparations to change their smoking behaviour. This suggests that interventions should focus on promoting movement toward the Preparation and Action stages of change.

Smoking and dietary inadequacy among Inuvialuit women of child bearing age in the Northwest Territories, Canada

Objective

The prevalence of smoking in Aboriginal Canadians is higher than non-Aboriginal Canadians, a behavior that also tends to alter dietary patterns. Compared with the general Canadian population, maternal smoking rates are almost twice as high. The aim of this study was to compare dietary adequacy of Inuvialuit women of childbearing age comparing smokers versus non-smokers.

Research methods & procedures

A cross-sectional study, where participants completed a culturally specific quantitative food frequency questionnaire. Non-parametric analysis was used to compare mean nutrient intake, dietary inadequacy and differences in nutrient density among smokers and non-smokers. Multiple logistic regression analyses were performed for key nutrients inadequacy and smoking status. Data was collected from three communities in the Beaufort Delta region of the Northwest Territories, Canada from randomly selected Inuvialuit women of childbearing age (19-44 years).

Results

Of 92 participants, 75% reported being smokers. There were no significant differences in age, BMI, marital status, education, number of people in household working and/or number of self employed, and physical activity between smokers and non-smokers. Non-parametric analysis showed no differences in nutrient intake between smokers and non-smokers. Logistic regression however revealed there was a positive association between smoking and inadequacies of vitamin C (OR = 2.91, 95% CI, 1.17-5.25), iron (OR = 3.16, 95% CI, 1.27-5.90), and zinc (OR = 2.78, 95% CI, 1.12-4.94). A high percentage of women (>60%), regardless of smoking status, did not meet the dietary recommendations for fiber, vitamin D, E and potassium.

Conclusions

This study provides evidence of inadequate dietary intake among Inuvialuit of childbearing age regardless of smoking behavior.

Pre-pregnancy predictors of hypertension in pregnancy among Aboriginal and Torres Strait Islander women in north Queensland, Australia; a prospective cohort study

Background

Compared to other Australian women, Indigenous women are frequently at greater risk for hypertensive disorders of pregnancy. We examined pre-pregnancy factors that may predict hypertension in pregnancy in a cohort of Aboriginal and Torres Strait Islander women in north Queensland.

Methods

Data on a cohort of 1009 Indigenous women of childbearing age (15–44 years) who participated in a 1998–2000 health screening program in north Queensland were combined with 1998–2008 Queensland hospitalisations data using probabilistic data linkage. Data on the women in the cohort who were hospitalised for birth (n = 220) were further combined with Queensland perinatal data which identified those diagnosed with hypertension in pregnancy.

Results

Of 220 women who gave birth, 22 had hypertension in the pregnancy after their health check. The mean age of women with and without hypertension was similar (23.7 years and 23.9 years respectively) however Aboriginal women were more affected compared to Torres Strait Islanders. Pre-pregnancy adiposity and elevated blood pressure at the health screening program were predictors of a pregnancy affected by hypertension. After adjusting for age and ethnicity, each 1 cm increase in waist circumference showed a 4% increased risk for hypertension in pregnancy (PR 1.04; 95% CI; 1.02-1.06); each 1 point increase in BMI showed a 9% adjusted increase in risk (1.09; 1.04-1.14). For each 1 mmHg increase in baseline systolic blood pressure there was an age and ethnicity adjusted 6% increase in risk and each 1 mmHg increase in diastolic blood pressure showed a 7% increase in risk (1.06; 1.03-1.09 and 1.07; 1.03-1.11 respectively). Among those free of diabetes at baseline, the presence of the metabolic syndrome (International Diabetes Federation criteria) predicted over a three-fold increase in age-ethnicity-adjusted risk (3.5; 1.50-8.17).

Conclusions

Pre-pregnancy adiposity and features of the metabolic syndrome among these young Aboriginal and Torres Strait Islander women track strongly to increased risk of hypertension in pregnancy with associated risks to the health of babies.

Pragmatic randomised trial of a 12-week exercise and nutrition program for Aboriginal and Torres Strait Islander women: clinical results immediate post and 3 months follow-up

Background

Aboriginal and Torres Strait Islander women experience higher rates of heart disease and type 2 diabetes than non-Indigenous Australian women. Increasing physical activity, improving diets and losing weight have been shown to reduce cardio metabolic risk. The primary aim was to evaluate the effectiveness of a 12-week structured exercise and nutrition program in a cohort of urban Indigenous Australian women on waist circumference, weight and biomedical markers of metabolic functioning from baseline (T1) to program completion (T2). The secondary aim assessed whether these outcomes were maintained at 3-month follow-up.

Methods

One hundred Aboriginal and/or Torres Strait Islander women aged 18–64 years living in the Adelaide metropolitan area were recruited. The program included two 60-minute group cardiovascular and resistance training classes per week, and four nutrition education workshops. Participants were randomly assigned to an ‘active’ group or ‘waitlisted’ control group. Body weight, height, waist and hip circumference, blood pressure, fasting glucose, fasting insulin, glycated haemoglobin (HbA1C), lipid profile and C-reactive protein (CRP) were assessed at baseline (T1), immediately after the program (T2) and three months post program (T3).

Results

The active group showed modest reductions in weight and body mass index (BMI). Compared to the waitlisted group, the active group had a statistically significantly change in weight and BMI from baseline assessments; at T2, ^-1.65 kg and ^-0.66 kg/m² and at T3, ^-2.50 kg and ^-1.03 kg/m², respectively. Systolic and diastolic blood pressure also had a statistically significant difference from baseline in the active group compared to the waitlisted group at T2, ^-1.24 mmHg and ^-2.46 mmHg and at T3, ^-4.09 mmHg and ^-2.17 mmHg, respectively. The findings were independent of the baseline measure of the outcome variable, age, households with children and employment status. Changes in waist circumference and other clinical measures were not significant at T2 or T3. The primary outcome measure, waist circumference, proved problematic to assess reliably. Missing data and participants lost to follow-up were significant.

Conclusions

This 12-week exercise program demonstrated modest reductions in weight, BMI and blood pressure at T2, which improved further at 3-month follow-up (T3). Positive intervention effects were observed despite low attendance at exercise classes. Structured exercise programs implemented in community settings require attention to understanding the barriers to participation for this high risk group.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12610000224022

Amphetamines, the pregnant woman and her children: a review

The objective of this study is to review and summarize available evidence regarding the impact of amphetamines on pregnancy, the newborn infant and the child. Amphetamines are neurostimulants and neurotoxins that are some of the most widely abused illicit drugs in the world. Users are at high risk of psychiatric co-morbidities, and evidence suggests that perinatal amphetamine exposure is associated with poor pregnancy outcomes, but data is confounded by other adverse factors associated with drug-dependency. Data sources are Government data, published articles, conference abstracts and book chapters. The global incidence of perinatal amphetamine exposure is most likely severely underestimated but acknowledged to be increasing rapidly, whereas exposure to other drugs, for example, heroin, is decreasing. Mothers known to be using amphetamines are at high risk of psychiatric co-morbidity and poorer obstetric outcomes, but their infants may escape detection, because the signs of withdrawal are usually less pronounced than opiate-exposed infants. There is little evidence of amphetamine-induced neurotoxicity and long-term neurodevelopmental impact, as data is scarce and difficult to extricate from the influence of other factors associated with children living in households where one or more parent uses drugs in terms of poverty and neglect. Perinatal amphetamine-exposure is an increasing worldwide concern, but robust research, especially for childhood outcomes, remains scarce. We suggest that exposed children may be at risk of ongoing developmental and behavioral impediment, and recommend that efforts be made to improve early detection of perinatal exposure and to increase provision of early-intervention services for affected children and their families.

Vitamin D levels in pregnant women booking for antenatal care in Far North Queensland

Serum concentrations of vitamin D were measured in pregnant women booking for antenatal care in Cairns Base Hospital, Queensland. Of 116 women, none was found to be vitamin D deficient. With a threshold of 50 nmol/L, no woman demonstrated vitamin D insufficiency; with a threshold of 75 nmol/L, 6.9% would have mild insufficiency. Further investigation into vitamin D concentrations of women living in northern Australia is required before recommendations are made for universal vitamin D screening of all pregnant women in Australia.

Jumping the Hurdles for Smoking Cessation in Pregnant Aboriginal and Torres Strait Islander Women in Australia

Tobacco smoking perpetuates the disadvantages experienced by Aboriginal and Torres Strait Islander people in Australia. Tobacco smoking is a risk factor for poor maternal and infant outcomes in pregnancy. Over half of Aboriginal and Torres Strait Islander women smoke during pregnancy and few successfully quit. Aboriginal and Torres Strait Islander women face many intrinsic barriers to quitting such as low socioeconomic disadvantage and patterns of use in family networks. There are also several extrinsic hurdles surrounding current practice guidelines and policy that may limit success in reducing smoking rates among Aboriginal and Torres Strait Islander women during pregnancy: the use of the Stages of Change (SOC) model; delay in the use of nicotine replacement therapy (NRT); and the absence of subsidised intermittent NRT. A more proactive approach towards smoking cessation for pregnant Aboriginal and Torres Strait Islander women may be necessary, including moving away from the SOC model approach and subsidised provision of intermittent NRT. Comprehensive programs that take into account the family network and wider social context are also recommended.

Epigenetic modifications may play a role in the developmental consequences of early life events

Many aspects of postnatal development are influenced by events before birth, including cognitive and language development. An adverse intrauterine environment, for example secondary to poor maternal nutritional status, multiple pregnancy, or late preterm birth, is associated with increased risks of delayed or impaired childhood development and altered physiology in adulthood that may predispose to increased risk of adult disease. Maternal periconceptional undernutrition and twin conception can both result in late preterm birth, but it is less clear whether cases of late preterm birth not following a recognized early pregnancy event may still have their origin in the periconceptional period. Thus, the very earliest periods of pregnancy, and perhaps even the pre-pregnancy period, may be an important period determining the developmental trajectory of the fetus, and thus both pregnancy and later health outcomes. Profound epigenetic modifications to the genome occur in the early embryo as a normal part of development. Recent evidence suggests that environmental signals acting during early development may also result in epigenetic changes which may play a role in mediating the association between early life exposures and later phenotype.

Diabetes prevalence and determinants in Indigenous Australian populations: A systematic review

AIMS

To perform a systematic review of the prevalence of diabetes and impaired glucose tolerance (IGT) in Indigenous Australians in order to clarify overall patterns, by determinants such as age, gender, region, ethnicity and remoteness.

METHODS

The OVID interface to Medline and the Australian Indigenous HealthInfoNet databases were systematically searched from years 1997 to 2010. Studies reporting diabetes prevalence were included if they used population-based samples of Indigenous Australians. Diagnosis of diabetes was based on self-report or standard diagnostic criteria.

RESULTS

Twenty-four studies were included. The diabetes prevalence ranged from 3.5 to 33.1%; IGT estimates ranged from 4.7 to 21.1%. Prevalence was greater among Indigenous Australian women compared to men, the Northern Territory's Top End compared to Central Australia, Torres Strait Islanders compared to Aboriginals, older (≥35 years) compared to younger (<35 years) age groups, and remote compared to urban settings. Patterns of IGT prevalence were similar to those observed for diabetes.

CONCLUSIONS

Although the prevalence of diabetes and IGT is high, there appears to be considerable variation in prevalence between different segments of the Australian Indigenous population. Data on diabetes prevalence in the urban Australian Indigenous population is lacking, despite accounting for almost three quarters of the total population.