Strategy 2015-2020 NT Health Nutrition and Physical Activity 2020 ...
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NT Health Nutrition and Physical Activity Strategy 2015–2020
DEPARTMENT OF HEALTH
Contents
Foreword2 Objective 3: optimise feeding practices
Acronyms5 and promote an active lifestyle for
children aged 0−5 years 24
Who is this strategy for and how
Background 24
can it be used? 6
What the data tell us 25
Aim6
Our challenge 26
Objectives6
Evidence for effective interventions 26
Key action areas and target group 6
Suggested strategies across settings 28
Related policies, strategies and guidelines 7 Indicators 28
Guiding principles 7 Stakeholders* 29
Working within a health
Objective 4: promote and support healthy
promoting framework 7
eating and regular participation in physical
Targeting the social determinants of health 7 activity among school aged children 30
Gender and diversity 7 Background 30
Providing cultural security 8 What the data tell us 31
Sustaining through capacity building 8 Our challenge 33
Working in partnership 8 Evidence of effective interventions 33
Commitment to monitoring and evaluation 8 Suggested strategies across settings 34
Summary of strategies 9 Indicators 35
Objective 1: improve food security, Stakeholders* 35
particularly in remote communities 14 Objective 5: achieve and maintain a
Background 14 healthy weight for all adults and older
What the data tell us 14 Territorians 36
Our challenge 16 Background 36
Evidence of effective interventions 16 What the data tell us 37
Suggested strategies 16 Our challenge 41
Indicators 17 Evidence of effective interventions 41
Stakeholders* 17 Suggested strategies across settings 42
Objective 2: promote and support a Indicators 44
healthy diet and a healthy weight among Stakeholders* 44
women of child bearing age 18 Appendix A: Australian Dietary Guidelines 45
Background 18
Appendix B: Australia’s physical activity
What the NT data tell us 20 and sedentary behaviour guidelines 46
Our challenge 21 National Physical Activity Recommendations
Evidence of effective interventions 21 for Children 0−5 years 46
Suggested strategies across settings 22 Physical Activity and Sedentary Behaviour
Guidelines for 5−12 and 13−17 year olds9;12 46
Indicators 22
Physical Activity and Sedentary Behaviour
Stakeholders* 22
Guidelines for 18−64 year olds1147
Physical Activity Recommendations for
Older Australians10 47
References 48
2
NT Health Nutrition and Physical Activity Strategy 2015–2020
Acronyms
AOD Alcohol and other Drugs
ABS Australian Bureau of Statistics
AHP Aboriginal Health Practitioner
ALPA Arnhem Lands Progress Aboriginal Corporation
CNW Community Nutrition Worker
CYH Child and Youth Health
DET Department of Education
DLPE Department of Lands, Planning and the Environment
DSR Department of Sport and Recreation
GP General Practitioner
MBS Market Basket Survey
MSHR Menzies School of Health Research
NHMRC National Health and Medical Research Council
OBS Outback Stores
PHC Primary Health Care
RMP Remote Medical Practitioner
RN Registered Nurse
SWSBSC Strong Women Strong Baby Strong Culture
SWW Strong Women Worker
WHSU Women’s Health Strategy Unit
MHSU Men’s Health Strategy Unit
STRATEGY SUMMARY
3
DEPARTMENT OF HEALTH 4
NT Health Nutrition and Physical Activity Strategy 2015–2020
Foreword
“It is no secret that healthy
nutrition and regular
physical activity are critical
to good health.”
It is no secret that healthy nutrition and regular determinants of a healthy and active lifestyle,
physical activity are critical to good health. whether these staff work in a policy context
Yet, for most of us, choosing healthier foods or ‘at the coal face’. It also leaves room for
and drinks and finding time to exercise has innovative and community driven responses.
never been harder. Not surprisingly rates of
As most contributing factors to poor nutrition
overweight and obesity are high, and rising,
or physical inactivity are outside the control
causing an alarming increase in prevalence of
of the Health sector, many of the proposed
diabetes and chronic diseases.
solutions will require collaboration with other
These issues present significant public sectors, within and outside government.
health problems that threaten the gains The strength of the NT is that in many cases,
made in earlier decades. They also place an these alliances already exist and are solid;
increasing burden on health budgets and much good work can therefore be expected
governments in general. by capitalising on them.
The Northern Territory (NT) has not been Finally, this strategy is grounded on health
immune to these developments and is now promotion principles; it acknowledges the role
facing high rates of chronic diseases. But that environments play in shaping individuals’
whilst we have an urgent responsibility to act decisions and aims to develop the conditions
on overweight and obesity, we must also tackle that will support changes. Only by making it
other nutrition issues, such as underweight easier for people to make healthy choices in
and anaemia among young children in the places they live, work and play, can we
remote communities. As we all know, these hope to turn the rising tide of chronic diseases.
issues must be addressed in the context
I thank all of those who gave their time and
of geographic isolation, limited enabling
attention to the development of this important
STRATEGY SUMMARY
infrastructure, and staff turnover.
document. It is with great pleasure that I
With these challenges in mind, this strategy commend to you the NT Health Nutrition and
draws on the available evidence to propose Physical Activity Strategy 2015−2020.
local solutions to NT specific problems.
It contains a comprehensive list of suggestions Professor Len Notaras AM
for staff who are able to influence the Chief Executive
5
DEPARTMENT OF HEALTH
Who is this strategy for Key action areas and
and how can it be used? target group
The Northern Territory Health (NT Health) • Reduce obesogenic environments by
Nutrition and Physical Activity Strategy developing policies and environments
2015−2020 (‘the strategy’) is intended for that support healthy eating and regular
staff within NT Health who are in a position to physical activity.
influence the determinants of a healthy diet • Promote healthy eating by encouraging
and an active lifestyle. and supporting
It provides an overview of the key health issues - exclusive breastfeeding for the first
associated with poor nutrition and physical 6 months of life
inactivity throughout the life course, brings
together the available evidence of interventions - the introduction of age appropriate
that have been effective in addressing them, solids at around 6 months
and suggests a range of strategic actions - increased consumption of fruit and
relevant to the NT context. vegetables
In practice, this strategy can be used as a - reduced intake of sugar sweetened
guide and practical tool for planning and beverages (SSBs)
evaluation across the spectrum of programs - reduced intake of other energy-dense
that have a remit in nutrition and physical nutrient-poor (EDNP) foods and drinks.
activity. It complements the Northern
Territory Chronic Conditions Prevention and • Promote participation in regular physical
Management Strategy 2010−2020¹ and activity throughout life.
supports its implementation. • Promote a reduction in time spent being
sedentary or sitting down.
Aim This strategy targets all Territorians, wherever
they live. It places however a special emphasis
This strategy aims to increase the proportion of
on Aboriginalª people living in remote
Territorians who enjoy a balanced diet, lead an
communities due to the higher burden of
active lifestyle and maintain a healthy weight,
disease and disadvantage they experience.
in order to enhance their health and wellbeing,
and reduce the risk and incidence of chronic
diseases and premature death. Related policies,
strategies and guidelines
Objectives • 2014−2017 Strategic Plan, Northern
Objective 1: improve food security, particularly Territory Health²
in remote communities. • Northern Territory Chronic Conditions
Objective 2: promote and support a healthy Prevention and Management Strategy
diet and a healthy weight among women of 2010−2020¹
child bearing age. • Northern Territory Work Health and Safety
Objective 3: optimise feeding practices and Act 2011³
promote an active lifestyle for children aged • Australian National Breastfeeding Strategy
0−5 years. 2010−20154
Objective 4: promote and support healthy • National Women’s Health Policy 20105
eating and regular participation in physical
activity among school aged children. • National Male Health Policy 20106
Objective 5: achieve and maintain a healthy • Australian Dietary Guidelines7
weight for all adults and older Territorians. • Australian Physical Activity
Recommendations and Guidelines.8-¹²
6 a Throughout this document the term Aboriginal should be taken to include Torres Strait Islander people
NT Health Nutrition and Physical Activity Strategy 2015–2020
Guiding principles • review service delivery practices to ensure
that they do not offend Aboriginal people’s
Working within a health culture and values
promoting framework • act to modify service delivery practices
where necessary
Consistent with NT Health’s Health Promotion
Framework13, this strategy promotes a • monitor service activity to ensure that our
continuum of health promotion practice. services continue to meet culturally safe
This continuum is reflective of the Ottawa standards.
Charter14 and relies on a range of approaches, This approach is extended to the provision
both individual and population-wide, designed of services to communities of culturally and
to complement one another as they target the linguistically diverse backgrounds.
determinants of health across the life course. Sustaining through capacity building
These approaches include:
A key element to the sustainability of all
• settings and supportive environments initiatives identified in this strategy is the
• community action building of capacity, within the community
• health information and social marketing or other agencies. Capacity building
encompasses training and support, sharing
• health education and skills development
knowledge, assisting with ensuring that the
• screening and individual risk assessment. infrastructure is in place, addressing the issue
of sustainability and facilitating the process of
Targeting the social problem solving and evaluation.
determinants of health
This strategy acknowledges the need to
Working in partnership
address the multiple underlying social, Implementation of this strategy will be a
economic and cultural determinants of health shared responsibility between a broad range
and aims to reduce health disparities seen in of stakeholders across the three entities
the NT, by focussing on those who experience forming the Public Health system in the NT.
the greatest disadvantage and are most at-risk. Many of the factors that impact on food supply,
Hence its strong focus on Aboriginal people nutrition or physical activity are however
living in remote communities, and particularly outside the responsibility of the health system.
on Aboriginal children under the age of two. For sustained improvements in these domains,
partnerships must therefore be established
Gender and diversity between relevant stakeholders across all levels
This strategy recognises other causal factors of government, the non-government sector,
of health inequity including: age; ethnic and research institutions, industry and
linguistic background; gender; incarceration; the community.
mental health status; physical and or
intellectual disability; and sexuality.
Commitment to monitoring
and evaluation
Providing cultural security The Nutrition and Physical Activity Strategy
Consistent with NT Health’s Aboriginal Cultural Unit will monitor performance against the
Security Policy15, this strategy promotes the objectives at mid-term and five years, and
STRATEGY SUMMARY
provision of culturally secure services that carry out the final evaluation.
• identify those elements of Aboriginal
culture that affect the delivery of health
and community services in the Northern
Territory
7
DEPARTMENT OF HEALTH
Summary of strategies • In partnership with local community
organisations, the non-government sector
Objective 1: improve food and Aboriginal organisations, support
community and school gardens, where
security, particularly in remote community capacity and willingness to
communities support the sustainable implementation of a
garden project are demonstrated.
In remote communities
• Contribute to projects researching
• Develop community capacity to influence
options to improve food security in
availability, variety, quality and affordability
disadvantaged areas.
of core foods at the store.
• Assist store/takeaway management and Objective 2: promote and
store committees to develop and implement
support a healthy diet and a
food and nutrition policies.
healthy weight among women
• Provide advice and learning opportunities
to store staff to develop and implement of child bearing age
initiatives that improve food supply and Pre-pregnancy
consumption of healthy food.
• With adolescent females of child bearing
• Contribute to store-based activities that age, emphasise the importance of healthy
promote and support a healthy diet. and balanced nutrition; in particular,
• Engage with Outback Stores (OBS), promote a diet high in iron-rich foods. Refer
Arnhem Land Progress Aboriginal to contraception counselling as required.
Corporation (ALPA) stores and other key • Promote folic acid and iodine supplements
food industry stakeholders to contribute to for all women planning a pregnancy (see
their efforts to ensure that the food supply Figure 3 page 21).
supports the Australian Dietary Guidelines7
• Develop and implement weight
(see Appendix A page 43).
management programs for women of
• Support research related to food systems childbearing age who are overweight
and factors that influence purchasing and or obese.
consumption decisions.
• Encourage smoking cessation.
• Build on existing housing initiatives to
improve community and household food During the pregnancy and the first
preparation and storage facilities. 6 weeks post-natal
• Advocate for initiatives to improve the • Encourage regular attendance at
affordability of healthy food and drinks antenatal clinics.
(e.g. cross-subsidisation).
• Incorporate specific weight management
Across the NT advice as part of regular antenatal care.
In particular, counsel teenagers on the
• Work with Community Stores Licensing
importance of adequate weight gain
(Australian Government) to ensure
during pregnancy.
availability of a range of affordable and
healthy food in all stores. • Promote key nutritional recommendations
for pregnancy (see Figure 3 page 21).
• Work with relevant government agencies,
as well as the agriculture, horticulture • Encourage regular physical activity to
and aquaculture industry, to support maintain general fitness and for good
the development of sustainable and blood glucose control in those women
economically viable projects. with diabetes.
• Promote smoking cessation and encourage
women not to drink alcohol during
pregnancy and lactation.
8
NT Health Nutrition and Physical Activity Strategy 2015–2020
Objective 3: optimise feeding • Build remote communities’ capacity to
support and promote the introduction of
practices and promote an solids and the development of healthy
active lifestyle for children feeding practices.
aged 0−5 years • Work with store managers to ensure
Key focus that displays of infant formula, bottles
and teats are consistent with the
• Systematic promotion of exclusive Marketing in Australia of Infant
breastfeeding for the first 6 months. Formulas (MAIF) Agreement.98
• Counselling about the introduction of
appropriate solids at around 6 months. In early childhood centres
• Early identification and action on growth • Provide education and assistance in
failure, anaemia or overweight. developing a nutrition policy and menu
planning, consistent with the Infant Feeding
• Promotion of regular physical activity and Guidelines97 and the requirements of the
limited screen time. Australian Children’s Education and Care
Within the health sector Quality Authority.
• Implement the National Breastfeeding Objective 4: promote and
Strategy4: develop an NT action and
implementation plan. support healthy eating and
• Integrate the systematic promotion of
regular participation in
breastfeeding into key messages and physical activity among school
practice for all health professionals. aged children
• Develop and/or enhance systematic In schools
data collection and reporting of
breastfeeding rates. • Promote and support the implementation
of the NT Schools’ Canteen, Nutrition and
• Identify growth failure, overweight, obesity Healthy Eating Policy.139
and anaemia early and ensure adequate
follow up. • Contribute to the development of strategies
that reduce energy-dense, nutrient-poor
• Contribute to national initiatives seeking (EDNP) foods and drinks in lunch boxes.
to reduce exposure to television or screen
based advertising of energy dense nutrient • Provide advice, training and support to
poor foods to children. teaching staff to deliver nutrition education
in schools.
In the home/families/community • Provide advice on the development of
• Promote exclusive breastfeeding up to curriculum related resources that promote
6 months. nutrition and physical activity and healthy
• Ensure that messages provided to parents body image.
about breastfeeding and introduction of • Advocate for the training of generalist
solids are consistent with the Infant Feeding teachers in fundamental movement skills
Guidelines.97 and physical education in general.
• Create supportive community environments • Advocate for strategies that will
STRATEGY SUMMARY
for the development of healthy eating increase adolescent girls’ participation
behaviour, including breastfeeding. in physical activity.
9
DEPARTMENT OF HEALTH
• Advocate for and support active transport Objective 5: achieve and
to school.
maintain a healthy weight for
• Advocate for active playgrounds and
all adults and older Territorians
opportunities for incidental activity
throughout the day. Within the health sector
• Contribute to the establishment of school • Create workplace environments where
based gardens. healthy eating and physical activity are
• Contribute nutritional advice to Out-of- easily achievable:
School Care programs, as required. - implement 'Healthy choices made
easy’, NT Healthy food and drinks
In other settings provision policy
• Support local government to develop and
- develop and implement an
implement childhood obesity prevention
Active@work policy
programs (e.g. COPAL in Palmerston).
- promote and support active transport to
• Provide training and support to health
and from work
professionals on child nutrition, physical
activity and healthy body image, - promote breaks in sedentary time.
consistent with current guidelines and • Strengthen the capacity of health
recommendations. professionals to address overweight and
• Promote the Australian Dietary Guidelines obesity by:
for Children7 and the Australian - promoting awareness of the risks
recommendations for physical activity for associated with weight gain and
children9;12; suggest home-based strategies the need to address even modest
to implement them. weight gain
• Develop partnerships with Good Sports and - promoting the NHMRC
key sporting bodies to reduce access to, recommendations for the management
and promotion of, EDNP foods and drinks of overweight and obesity in adults,
at sporting events. children and adolescents.
• Promote ‘child friendly by design’ • Ensure that the NTG leads by example,
approaches to influence the development by advocating for the adoption of the NT
of the built environment and public open Healthy food and drinks provision policy
spaces so that they incorporate safe active across all NTG agencies.
play and transport options. • Advocate for, and actively contribute to,
• Research and implement innovative the development of government policies
strategies to include fathers in nutrition and that have a positive impact on the
physical activity promotion. determinants of overweight and obesity
• Contribute to national initiatives seeking to (e.g. food/active transport policy at national
reduce exposure to advertising of EDNP and Territory level).
foods and drinks to children. • Advocate for the integration of Healthy by
Design principles177 in urban developments.
• Advocate for the shared use of facilities that
provide opportunities for physical activity
(e.g. school grounds).
• Contribute to national efforts seeking
the stronger regulation of marketing of
unhealthy foods and drinks, particularly
EDNP products.
10NT Health Nutrition and Physical Activity Strategy 2015–2020
• Advocate for, and support, Australian • Promote participation in lifestyle
Government regulatory initiatives in food modification programs (such as Eat Better,
reformulation and labelling to support Move More).
healthier eating. • Contribute to the development of
In the community community based sustainable sport
and recreation programs/ policies/
• Increase community awareness of the infrastructure, which cater for both men
need to eat well and be active through and women across all age groups.
social marketing
• Contribute to the upskilling of key
- disseminate and promote the Australian community stakeholders in physical
Dietary Guidelines7 activity and nutrition (e.g. sport and
- disseminate and promote the Physical recreation officers).
Activity Guidelines for adults11 • Develop a culture of ‘choosing water’ over
- support national or NGO driven sugar sweetened beverages (SSBs) through
campaigns and initiatives, as they are the ‘Swap soft drinks for water’ initiative.
developed (e.g Live lighter).
In commercial and non-commercial
• Build on and support local government/
regional council/ community initiated food services
programs that assist individuals and groups • Encourage services in commercial, non-
to embrace a healthy lifestyle (e.g. Healthy commercial and institutional premises
Darwin), particularly in low SES areas and (e.g. hospitals, aged care institutions, jails,
remote communities. hostels) to provide meals in line with the
• Assist local government and community Australian Dietary Guidelines.7
based organisations to develop and • Encourage managers of remote community
implement healthy eating/catering policies. takeaways to provide food in line with the
• Advocate for the development of Australian Dietary Guidelines.7
environments that support active In sports clubs and associations
living across all ages and for all abilities,
• Engage in partnership with local sporting
and include easy and safe access to public
clubs, as a setting where healthy behaviours
open spaces, schools or food retail/shopping
can be role modelled and promoted.
outlets that promote universal access.
• Contribute to the development of healthy
In remote communities catering/fundraising activities that support
• Facilitate gendered community based healthy food and drink options and are in
opportunities for cooking and food line with the Australian Dietary Guidelines.7
preparation learning sessions.
• Engage men in targeted nutrition
interventions that relate to chronic
disease prevention and management.
• Support and encourage middle aged
men and women to continue to engage
in regular physical activity after they stop
STRATEGY SUMMARY
playing sports.
11Objective 1:
Improve food security, particularly
in remote communities
Background
Food security has been defined as the ability of individuals, households
and communities to acquire appropriate and nutritious food on a regular
and reliable basis, using socially acceptable means.16
Food security is determined by people’s local food supply and their capacity and resources to
access and use that food. Food security is strongly associated with a sustainable food system that
encourages local production and distribution infrastructures.
In the NT, 30.4% of the population is Aboriginal and three quarters of that group (74%) live in
remote areas, in low socio-economic circumstances. In remote communities most of the food
eaten is food purchased from the store and/or the takeaway. Despite noted recent improvements17,
the availability and the variety of foods available in these communities remain more limited than in
regional centres, and prices are significantly higher, suggesting the likelihood of food insecurity.
While healthy food is more readily available in urban centres, it may be equally unaffordable for
people living on low income or welfare payments, resulting as well in food insecurity or what has
been labelled ‘food stress’.18
It has been postulated that people on limited income may opt for low cost energy-dense
nutrient-poor (EDNP) foods and drinks in order to maximise energy availability per dollar spent.19
The resulting poor diet is a major risk factor for chronic diseases such as type 2 diabetes,
gestational diabetes, cardiovascular disease, hypertension and renal disease, all of which have a
high prevalence in the Aboriginal population.20 Poor diet also contributes to dental caries.
The impact of improving the supply of healthy food and drinks is greatest when it is coordinated
with actions that promote healthy eating and increase demand for healthy food and drinks.
12NT Health Nutrition and Physical Activity Strategy 2015–2020
What the data tell us
In 2014, data collected as part of the NT A 2012 study in Adelaide found that low-
Market basket Survey (MBS)17 showed that a income families would have to spend
healthy food basket was 53% more expensive approximately 30% of household income
in remote community stores than in a Darwin on eating healthily, whereas high-income
supermarket (see Figure 1 page 13). households needed to spend about 10%.18
That same year, the proportion of incomeb A review of the literature describing the link
required to purchase the food basket was between poverty, food insecurity and obesity,
34% in remote stores, compared with 22% in with specific reference to Australia, has shown
a Darwin supermarket. There has been little that the risk of obesity is 20 to 40% higher
variation in this difference over the last three among people affected by food insecurity.21
years (see Figure 2 page 14).
FIGURE 1: COST OF THE FOOD BASKET, REMOTE STORES COMPARED WITH THE DARWIN SUPERMARKET, 2000–201417
900 60
800
50
700
600 40
500
30
400
300 20
200
10
100
OBJECTIVE 1
0 0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
DARWIN SUPERMARKET REMOTE STORES PERCENTAGE DIFFERENCE
b Income is calculated annually from the sum of welfare payments that the hypothetical family is entitled to receive. For more details,
see the Market basket survey at http://digitallibrary.health.nt.gov.au/dspace/simple-search?query=%22market+Basket%22.
13DEPARTMENT OF HEALTH
Our challenge
We must • monitoring and providing feedback
to participants
• contribute to increased access to a
healthy and affordable food supply, • modifying strategies according to need.23
wherever people live
• build nutrition knowledge and skills, and
Suggested strategies
stimulate demand for a healthy diet. In remote communities
• Develop community capacity to influence
Evidence of effective availability, variety, quality and affordability
interventions of core foods at the store.
Research shows that store managers can have • Assist store/takeaway management and
considerable influence over the food supply store committees to develop and implement
in remote communities, and that working food and nutrition policies.
in partnership with them can benefit the • Provide advice and learning opportunities
community’s dietary intake.22 to store staff to develop and implement
Overall, there is a paucity of well-designed initiatives that improve food supply and
and well evaluated food security programs, consumption of healthy food.
particularly those targeting remote • Contribute to store-based activities that
communities. The few documented successful promote and support a healthy diet.
interventions include the following best practice
• Engage with Outback Stores (OBS), Arnhem
elements:
Land Progress Aboriginal Corporation
• community involvement and support at all (ALPA) stores and other key food industry
stages of the project stakeholders to contribute to their efforts
• empowering the community rather than to ensure that the food supply supports
imposing priorities the Australian Dietary Guidelines7 (see
Appendix A page 43).
• multifaceted interventions addressing both
supply of and demand for ‘healthy’ food • Support research related to food systems
and factors that influence purchasing and
consumption decisions.
FIGURE 2: PROPORTION OF INCOME REQUIRED TO PURCHASE THE FOOD BASKET IN REMOTE STORES, COMPARED WITH
DISTRICT CENTRE SUPERMARKETS, 2000 TO 2014
45
40
35
30
25
20
15
10
5
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
DARWIN SUPERMARKET REMOTE STORES
Source: 2014 Market basket Survey (MBS)17
14NT Health, Nutrition and Physical Activity Strategy 2015–2020
• Build on existing housing initiatives to Indicators
improve community and household food
• Trends in availability, variety, quality
preparation and storage facilities.
and relative costs of food in remote
• Advocate for initiatives to improve the communities.
affordability of healthy food and drinks
• Proportion of population consuming
(e.g. cross-subsidisation).
the recommended serves of fruit and
Across the NT vegetables.
• Work with Community Stores Licensing • Establishment of community/
(Australian Government) to ensure school gardens.
availability of a range of affordable and • Establishment of agricultural, horticultural
healthy food in all stores. or aquacultural projects.
• Work with relevant government agencies,
as well as the agriculture, horticulture
Stakeholders*
Environmental Health Program; Department of
and aquaculture industry, to support
Housing; Department of Primary Industry and Fisheries;
the development of sustainable and Department of Justice (Consumer and Business Affairs);
economically viable projects. Power and Water Corporation; Australian Government
Department of Prime Minister and Cabinet – Community
• In partnership with local community Stores Licensing team; Australian Government
organisations, the non-government sector Department of Social services; MSHR; ALPA; OBS; Food
and Aboriginal organisations, support wholesalers and manufacturers; Store committees; Store
community and school gardens, where managers and staff; Community Councils; Aboriginal
community capacity and willingness to Land Councils; Fred Hollows Foundation and other
agencies involved in food supply in remote communities;
support the sustainable implementation of Remote Indigenous Gardens (RIG Network).
a garden project are demonstrated.
* See Acronyms page 3
• Contribute to projects researching
options to improve food security in
disadvantaged areas.
OBJECTIVE 1
15Objective 2:
Promote and support a healthy diet and a healthy
weight among women of child bearing age
Background
‘The 1,000 days between a woman’s pregnancy and her
child’s 2nd birthday offer a unique window of opportunity
to shape healthier and more prosperous futures. The
right nutrition during this 1,000 day window can have
a profound impact on a child’s ability to grow, learn, and
rise out of poverty. It can also shape a society’s long-term
health, stability and preprosperity.’24 [emphasis added]
The capacity of a woman to carry out a healthy pregnancy is influenced by
a number of factors and her own health since birth.25 Her nutritional status
in particular has a critical impact on the development of the foetus and birth
outcomes. The focus on maternal nutrition should therefore not be limited to
the pregnancy period but also include childhood and adolescence, and the
peri-conceptual period.25
A number of factors interact with nutrition to impact on intrauterine
growth and birth outcomes which also require attention. These include
mothers’ characteristics and behaviours, exposure to infections and the
socio-economic environment.
16NT Health Nutrition and Physical Activity Strategy 2015–2020
Key maternal nutrition or nutrition-related factors
impacting on foetal development and birth outcomes
Anaemia birthweight (macrosomia), birth injuries
due to shoulder dystocia or cephalo-
Iron deficiency anaemia is a risk factor for
pelvic disproportion, respiratory distress
maternal and perinatal mortality, preterm
and hypoglycaemia.30 In the long term,
delivery and subsequent low birthweight,
it is associated with increased risk of
delayed mental development and possibly
obesity, impaired glucose tolerance and
inferior neonatal health.26;27
type 2 diabetes in early adulthood.30
Diabetes in pregnancy • Gestational diabetes mellitus
Whether pre-existing (type 1 or type 2 - For mothers, it is associated with a
diabetes) or developing in pregnancy as difficult birth, increased chance of
gestational diabetes mellitus (GDM), diabetes having an induced birth and caesarean
in pregnancy increases the risk of serious short birth due to the large size of the baby.
and long term complications in both mother In the long-term, it places mothers
and child. at increased risk of recurrent GDM
• Pre-existing diabetes in subsequent pregnancies and of
- For mothers, it is associated with progression to type 2 diabetes.
a higher risk of miscarriage, pre- - Babies of mothers with GDM are
eclampsia, giving birth preterm or at increased risk of stillbirth, high
by caesarean section, and the first birthweight, post birth hypoglycaemia,
appearance or progression of diabetes- shoulder dystocia, respiratory distress
related kidney and ophthalmic and jaundice. Babies may also be at
complications.28;29 increased risk of obesity, impaired
- For babies, it is associated with glucose tolerance and type 2 diabetes
OBJECTIVE 2
congenital malformations of the spine, in early adulthood.30;31
heart and kidneys, stillbirth, high
17DEPARTMENT OF HEALTH
Weight
• Pre-pregnancy overweight or obesity and Note that more research is needed to
large gestational weight gain can strongly determine the suitability of these guidelines for
increase the risk of having a large baby.32 adolescents or women from different ethnic
Large for gestational age babies have a backgrounds.39
higher risk of birth injury and complications
of low blood sugar after delivery.32;33 Other modifiable factors
• Pre-pregnancy underweight is associated • Maternal smoking is associated with growth
with intrauterine growth restriction restriction and low birth weight45 and is
(IUGR)34 and increased prevalence of considered the largest known determinant
some pregnancy complications, such as of IUGR in developed countries.25 Recent
preterm birth and low birthweight.35 The research also suggests that mothers who
latter may have serious consequences as smoke during pregnancy have children at
low birthweight infants, particularly those higher risk of obesity in later years.46 The
who experience a rapid weight gain in likelihood of smoking decreases with higher
childhood, are at increased risk of obesity, levels of schooling.
insulin resistance, the metabolic syndrome,
• Alcohol consumption during pregnancy
type 2 diabetes, hypertension, and coronary
may result in miscarriage and stillbirth. It
heart disease later in life. 32;36-38
is also associated with prematurity, brain
• Low pregnancy weight gain is associated damage, birth defects, growth restriction,
with poor foetal growth, low birth weight, developmental delay and cognitive, social,
preterm birth and infant death.25;39 emotional and behavioural deficits.47;48
• Excess weight gain during pregnancy is • Stress can also have an impact on women’s
associated with pre-eclampsia, caesarean nutritional status, and consequently affect
delivery40, large for gestational age babies the development of the fetus.25
and increased risk of overweight for the
• Young maternal age may impair foetal
child by the age of 3.41;42
development, particularly in the case
• The NHMRC recommends to measure of teenage mothers whose growth is
all women’s weight and height at the first incomplete, as the nutritional needs of
antenatal visit and calculate their BMI.43 the mother’s body compete with those of
Whilst there are no Australian guidelines the fetus.25
for weight gain during the pregnancy, the
• Poverty or low socio-economic
US Institute of Medicine (IOM) provides
circumstances, during childhood and
guidance on weight gain in pregnancy
throughout the pregnancy, underpin many
based on prepregnancy BMI 44:
of the factors described above.
Pre-pregnancy Body Mass Index (BMI) Total weight gain (kg) Rates of weight gain 2nd and
3rd trimester (kg/week)*
underweight (BMI30) 5−9 0.22 (0.17 – 0.27)
* Calculations assume a 0.5-2kg weight gain in the first trimester
18NT Health Nutrition and Physical Activity Strategy 2015–2020
What the NT data tell us
Anaemia Nine percent of all Aboriginal mothers were
aged less than 18 years, compared with only
In 2012, rates of maternal anaemia were 0.7% of non-Aboriginal mothers. This pattern
around 14%, among Aboriginal mothers.49 of markedly earlier childbearing among
Type 2 diabetes and GDM Aboriginal mothers was seen in all health
• In 2010, pre-pregnancy rates of type districts including urban areas.52
2 diabetes were six times higher for Ante-natal care
Aboriginal women than for non-Aboriginal
women (3.53% and 0.58% respectively). In 2010, overall, women in urban areas
were more likely to attend an antenatal visit
• Rates of GDM were also higher amongst in the first trimester than those living in
Aboriginal women than non-Aboriginal rural or remote areas. This applied to both
women (8.3% and 5% respectively).50 Aboriginal and non-Aboriginal mothers.
Smoking Aboriginal mothers were more likely to have
insufficient antenatal care (no antenatal visit
In 2010, smoking prevalence at first visit or
or attended less than four visits) compared
at under 20 weeks was 37.9% for Aboriginal
with non-Aboriginal mothers (13% and 1%
women and 11.5% for non-Aboriginal women.
respectively).52
Smoking prevalence at any time during
pregnancy was 38.5% for Aboriginal women
and 11.6% for non-Aboriginal women.51
Our challenge
Alcohol consumption We must
• continue to reduce rates of
In 2010, at first antenatal visit, 6% of all NT
maternal anaemia
mothers reported drinking alcohol during
pregnancy. The prevalence of alcohol • reduce risk factors for diabetes (e.g. rates
consumption was higher among Aboriginal of pre-pregnancy overweight and obesity)
mothers (13% at the first visit and 7% at 36 • ensure healthy gestational weight gain
weeks gestation) than non-Aboriginal mothers
• reduce rates of smoking during pregnancy.
(3% and 1%, respectively).52
Overweight/obesity Evidence of effective
No data are available for NT women during interventions
pregnancy. A recent Australian longitudinal
A review of interventions for preventing
study of measured pregnancy weight gain
unintended pregnancies among adolescents
showed that 38% of participants gained weight
reported that all interventions including
in excess of the IOM guidelines (see page
education, contraception education and
19) during their pregnancy. Fifty-six percent
promotion, and combinations of education and
of overweight women gained excess weight
contraception promotion, reduced unintended
compared with 30% of those who started with
pregnancy over the medium term and long
a healthy weight.53 Of concern was the fact
term follow up period.55
that at 16 weeks, 47% of participants were
unsure of the weight gain recommendations Smoking cessation interventions in pregnancy
for them. reduce the proportion of women who continue
to smoke in late pregnancy, and reduce low
Mothers’ age birthweight and preterm birth.56 There is
In 2010, a fifth (20%) of Aboriginal mothers evidence that partners play a powerful role
OBJECTIVE 2
were less than 20 years of age at the time in determining whether pregnant women
of giving birth, almost seven times higher quit smoking and whether they are able to
than the 3% of non-Aboriginal mothers. maintain abstinence in the postpartum period.
19DEPARTMENT OF HEALTH
Compared to pregnant women who live with Suggested strategies across
non-smokers, those who live with a partner
who smokes are less likely to stop smoking settings
during pregnancy and more likely to relapse Pre-pregnancy
during the postpartum period.57
• With adolescent females of child bearing
There is some evidence that health promotion age, emphasise the importance of healthy
interventions are associated with some positive and balanced nutrition; in particular,
maternal behavioural change, including lower promote a diet high in iron-rich foods. Refer
rates of binge drinking.58 to contraception counselling as required.
There is insufficient evidence to recommend, • Promote folic acid and iodine supplements
or advise against, pregnant women with for all women planning a pregnancy (see
diabetes enrolling in exercise programs Figure 3 page 21).
in order to improve glycaemic control
and maintain a healthy weight.59 There • Develop and implement weight
is also insufficient evidence to guide management programs for women of
recommendations around physical activity to childbearing age who are overweight
prevent gestational diabetes.60 or obese.
A meta-analysis showed that antenatal • Encourage smoking cessation.
dietary programs targeting obese women During the pregnancy and the first
were effective in reducing the total gestational
weight gain, without detrimental effect on
6 weeks post-natal
the weight of the baby.61 A systematic review • Encourage regular attendance at
has shown that monitored physical activity antenatal clinics.
interventions appear to be successful in • Incorporate specific weight management
limiting gestational weight gain.62 advice as part of regular antenatal care.
Approaches that take into consideration both In particular, counsel teenagers on the
the nutritional status of the mother and other importance of adequate weight gain
social or environmental factors amenable to during pregnancy.
change are likely to be more effective than • Promote key nutritional recommenda¬tions
single focus one. A lifecourse approach to for pregnancy (see Figure 3 page 21).
maternal health based on multi-disciplinary
• Encourage regular physical activity to
collaboration is important to ensure optimum
maintain general fitness and for good
foetal development and birth outcomes.
blood glucose control in those women
with diabetes.
PREVENTING ANAEMIA
• Promote smoking cessation and encourage
Eat foods high in iron every day women not to drink alcohol during
- best: liver* and kidney, red meat, pregnancy and lactation.
chicken, fish
- good: iron enriched bread and cereals Key messages for women of child
(wholegrain), green leafy vegetables, bearing age
egg yolk, legumes. • Eat well, be active and maintain
Have foods high in vitamin C with meals, a healthy weight throughout
to help absorb iron: bush berry, oranges, your life
mandarin, pawpaw, capsicum, broccoli. • Eat iron rich foods and
* Pregnant women should limit their continue to be active during the
intake of liver to 100 g per week due pregnancy
to the high concentration of Vitamin A
• Don’t smoke and don’t drink
in liver.
alcohol while pregnant
Source : adapted from CARPA STM 6th ed 54
20NT Health Nutrition and Physical Activity Strategy 2015–2020
Indicators Stakeholders*
• Rates of smoking during pregnancy. Alcohol and other Drugs Program; CYH Program;
Women’s Health Unit; Men’s Health Unit; Community
• Rates of pre-pregnancy overweight Health Nurses; RNs; AHPs; RMPs; GPs; midwives;
and obesity. SWSBSC Program; SWWs; CNWs; relevant community
health groups (e.g. Australian Breastfeeding Association,
• Mean birthweight. Childbirth Education Association, Family Planning
• Proportion of low birthweight babies. Association); training institutions (e.g. Batchelor Institute
of Indigenous Tertiary Education, Charles Darwin
• Proportion of macrosomic babies. University); MSHR; Heart Foundation.
* See Acronyms page 3
FIGURE 3: KEY AUSTRALIAN NUTRITIONAL RECOMMENDATIONS FOR PREGNANCY
Pregnant women should Pregnant women should
avoid alcohol. • enjoy a variety of fruits and vegetables of
Pregnant women are at greater risk of food different types and colours
poisoning and should prepare and store food • increase their grain consumption, mostly
carefully. They should avoid: wholegrain, in preference to discretionary
• foods which may contain listeria choices
bacteria like soft cheeses (brie, camembert, • choose foods high in iron, such as lean
ricotta, feta and blue cheese), sandwich red meat or tofu, which are important for
meats, bean sprouts, pre-prepared salads pregnant women
and pâté • make a habit of drinking milk, eating hard
• raw eggs as they may contain salmonella cheese and yoghurt, or calcium enriched
• fish that may contain high levels of mercury alternatives-reduced fat varieties are best
– Food Standards Australia New Zealand • enjoy a wide variety of vegetables, legumes,
recommend consuming no more than fruit and wholegrains and drinking plenty of
one serve* (100g cooked) per fortnight of water every day can assist with constipation
shark/flake, marlin or broadbill/ swordfish, –a common occurrence during pregnancy
and no other fish that fortnight, or one • limit discretionary foods and drinks high in
serve (100g cooked) per week of orange saturated fat, added sugars and added salt
roughy (deep sea perch) or catfish and no such as cakes, biscuits and potato chips.
other fish that week
A daily folic acid supplement (0.5 mg/day)
• foods such as nuts during pregnancy only is recommended for women planning a
if they are allergic to the foods themselves pregnancy and during the first three months of
– avoiding these foods has no impact a pregnancy, in addition to eating foods which
on the infant’s risk of developing allergy are naturally rich in folate or are fortified with
symptoms. folic acid.
Steady weight gain during pregnancy is normal A daily iodine supplements (150 mcg/day)
and important for the health of the mother and is recommended for women planning a
baby. However, it is also important not to gain pregnancy, throughout pregnancy and
too much weight. while breastfeeding.
OBJECTIVE 2
Source: Adapted from Australian Dietary Guidelines brochure
Healthy eating during your pregnancy63and Minymaku Kutju
Tjukurpa – Women's Business Manual, 5th ed 64
21Objective 3:
Optimise feeding practices and promote an active
lifestyle for children aged 0−5 years
Background
Adequate nutrition and physical activity are vital for
optimal health and development in childhood. A child’s
nutritional status is strongly influenced by food security,
adequate care and the underpinning socio-economic and
cultural environment.65
Undernutrition in infancy results in poorer health and
social outcomes throughout life.
It is critical to act early to prevent undernutrition and obesity in children.
After age two the effects of undernutrition on childhood growth and
development are largely irreversible.66 Hence the need for interventions
during the ‘first 1000 days’ (see box page 16) or the window of opportunity
defined by pregnancy and the first two years of life.67
22NT Health Nutrition and Physical Activity Strategy 2015–2020
PHOTO: CITY OF DARWIN
Health impacts of malnutrition
Undernutrition in early childhood occurs when Currently, treatment includes giving iron orally
the transition to solids is inadequate both in or iron by intra muscular injection.73
quantity and/or quality, and/or untimely. This Low birthweight, combined with rapid
may lead to stunting or wasting, impaired growth in early life, is associated with a
immunity and increased susceptibility to number of chronic conditions in adulthood,
infection, which establish a self-perpetuating such as overweight or obesity, heart disease
cycle of infection-malnutrition.71 and diabetes.65;75
Children who are wasted, have a higher ri Overweight and obesity in childhood tracks
sk of death than children of adequate weight into adulthood, contributing to increased risk
for height.72 of chronic disease in adulthood.76 Maternal
A stunted child is likely to remain short in obesity is the most significant predictor of
stature throughout life, with associated risks childhood obesity, however other associated
that continue to the next generation.65 Stunting risk factors include: low birthweight combined
is also associated with delayed mental and with rapid growth in early life, intrauterine
motor development, which result in long term, exposure to gestational diabetes and low
irreversible deficits.69 socioeconomic status. Research also points to
Anaemia is most commonly the result of both pre-natal and stressful life events during
inadequate dietary iron intake or absorption, pregnancy as important determinants of later
and frequent intestinal infection. Other obesity risk, for example death of a family
contributors are low birthweight, low iron member or exposure to violence.77
stores in the mother before and during In young children, growth faltering and obesity
pregnancy, specific complementary feeding may go unrecognised by carers unless the
practices–such as delayed introduction of child’s growth (length, height and weight) is
solids, inadequate quantity of iron-rich foods, monitored against child growth standards.
and drinking cow’s milk before 12 months of
age.73 Iron deficiency anaemia is associated
OBJECTIVE 3
with poor growth, impaired cognitive and
motor development, increased susceptibility
to infection and reduced aerobic capacity.74
23DEPARTMENT OF HEALTH
What the data tell us
The critical issues for NT children under the Mild iodine deficiency has been reported in
age of 5 are: young people the Top End region before the
• high rates of low birthweight, chronic introduction of mandatory iodine fortification
undernutrition (particularly stunting) of salt in bread, with females (including those
and anaemia, mostly amongst Aboriginal who are pregnant and breastfeeding) most
children living in remote communities affected.81 The status of other micronutrients
is unknown. It is reasonable to assume that
• emerging overweight and obesity in where undernutrition exists, micronutrient
urban communities. deficiencies may also be present – particularly
In the NT the proportion of low birthweight in regards to calcium, zinc and folate.
babies born to Aboriginal mothers is more than Overweight and obesity is becoming
double that born to non-Aboriginal mothers more prevalent in very young children in
(13.8% and 5.7% respectively).78 Australia and recent data suggest that about
The prevalence of undernutrition is high, 20% of children aged 2−3 are overweight or
specifically among Aboriginal children, obese.82 In South Australia, urban Indigenous
and is attributed to an insufficient intake of children have been found to be at higher risk
age-appropriate complementary foods.79 In of obesity than non-Indigenous children.83 In
2014, 17% of Aboriginal children under the the NT, in 2011, 15.1% of urban Aboriginal
age of 5 and living in remote communities children aged 4–6 years were overweight or
were stunted; 7% were underweight and obese compared to 11.6% of urban non-
5% wasted.80 The highest prevalence of Aboriginal children, and 6.3% of remote
stunting was found in children aged 1−3 Indigenous children.84
years, where the rate of stunting was as high Breastfeeding initiation rates in the NT are
as 24%, compared with 13% for the under the highest in Australia, at 99%, compared to
12 months age group and 12% for the 3−5 around 90% elsewhere.85 Rates and length
years. Rates of anaemia were also highest in of exclusive breastfeeding are however not
the under 12 months and 1−3 years, at 31% available as there are significant gaps in data
and 24% respectively. Note that caution must available on breastfeeding rates. Overall,
be exercised when interpreting these data as children who live in remote areas are more
coverage was in some cases as low as 50%. likely to have been breastfed than those living
in major cities (85% and 72% respectively).86
MALNUTRITION illness.69 A child whose height for age Z score
Malnutrition refers both to undernutrition is less than -2SD is considered stunted.
(associated with stunting, wasting, and Overweight and obesity:
micronutrient deficiencies) and overweight - under 2, WHO recommends weight-for-
and obesity.68 height z score of WHZ +2 as overweight,
Wasting is defined as low body weight in WHZ +3 as obese.
relation to height, due to inadequate energy - 2-18, overweight and obesity can be defined
intake.68 A child whose weight-for-height Z according to age and gender-specific BMI cut-
score is less than −2 SD is considered wasted. offs*, which match adult BMI of 25 and 30.
Stunting is defined as low height or length in * determined by the International Obesity
relation to age and is predominantly due to Task Force (IOTF)70
chronic inadequate food intake and frequent
24NT Health Nutrition and Physical Activity Strategy 2015–2020
Our challenge
We must Ensuring appropriate infant and early
childhood feeding practices along with
• reduce rates of low birthweight (this is also adequate nutrient intake by pregnant women
addressed in ‘Section 2: women of child and micronutrient supplementation are
bearing age’) some of the best preventive measures to
• reduce rates of stunting, wasting and reduce the incidence of undernutrition in
anaemia children younger than 5 years, in developing
• prevent and address the development of countries.72 Feeding practices that encourage
overweight and obesity. a variety of food tastes and textures and
support the infant’s innate appetite regulation
Evidence for effective are known to help develop healthy food
behaviours in children.89
interventions
Promoting [Exclusive] Reducing and preventing anaemia
Breastfeeding Strategies to help prevent iron deficiency in
young children72 include routine iron and folate
Compared to a range of preventive supplements to pregnant women, fortification
interventions to improve child health, of staple foods with iron, micronutrient
breastfeeding is shown to have the greatest supplementation, deworming and delayed
impact on health because it provides nutrition cord clamping. Iron-rich foods should be
and immune protection for babies.87 In the first the first foods to be introduced at around 6
6 months of life, the risk of diarrhoea and all- months to complement breast milk.90
cause mortality is lowest in babies exclusively
breastfedc compared with babies who were In developing countries, home fortification
either not breastfed or partially breastfed.69 of foods with multiple micronutrient powders
is recommended by WHO to improve iron
Nearly all women can breastfeed successfully, status and reduce anaemia among infants
when given appropriate support. Breastfeeding and children 6–23 months of age.91 The
and nutrition counselling delivered by trained evaluation92 of the NT Early Childhood
health professionals or community workers is Nutrition and Anaemia Prevention Project
an effective intervention to improve exclusive (ECNAPP)d stressed the need for routine
breastfeeding rates.72 antenatal and child growth and development
The promotion of breastfeeding is an important checks, as well as treatment according to
public health strategy, driven at national level relevant protocols.
by the Australian National Breastfeeding
Strategy 2010−2015.4
Fostering a stimulating
environment
Reducing and preventing
In addition to nutrition, a child’s early
undernutrition environment can also impact on development,
Recommended actions are community based as evidenced by a study showing that stunted
counselling and multi-faceted interventions children who experienced psycho-social
integrated into the primary health care stimulation through play at age 9−24 months,
system.79 sustained benefits at 18 years of age.93
OBJECTIVE 3
c Exclusive breastfeeding means that the infant receives only breast milk. No other liquids or solids are given – not even water – with
the exception of oral rehydration solution, or drops/syrups of vitamins, minerals or medicines.88
d The Early Childhood Nutrition and Anaemia Prevention Project (ECNAPP), also called ‘Sprinkles’, was a research project set up
to determine the feasibility and acceptability of a community nutrition program to prevent anaemia and improve the nutrition of
Indigenous infants and young children aged 6 - 24 months. The objectives of the project were to:
• improve knowledge and practices of carers of 0 - 24 month old infants and young children about optimal infant and young child
feeding and anaemia prevention
• provide a preventive home micronutrient supplement (‘Sprinkles’) to 6-24 month olds
• inform future policy and program development to prevent nutritional anaemia and improve infant and young child nutrition.
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