Public Health Sciences (School of)

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The Diets of On-reserve First Nations Youth: An Exploration of the Factors Associated with Healthy Food Choices and the Impact of School and Community Programs
(University of Waterloo, 2016-01-19) Gates, Allison
Background. In Canada, First Nations (FN) people experience poorer health outcomes and shorter life expectancies than non-Aboriginal people. Of particular concern are the high and rising prevalence rates of overweight and obesity. This is especially true of on-reserve populations, who may be lacking in the opportunities and resources necessary to facilitate healthy lifestyles (e.g., reasonably priced healthy foods, access to organized sports or recreation facilities). The development of obesity for FN people is exceptionally complex and not well understood, although energy intake is a known contributor. The contributors to the food choices of young people are also numerous, interacting and complex. This is compounded by the severe and lasting effects of colonialism and marginalization, which have left much of the Canadian FN population disadvantaged with respect to many of the social determinants of health and distanced them from their culture. First Nations Canadians have, as a result, undergone a relatively rapid and recent transition towards a more ‘Western’ way of life that is increasingly reliant on store-bought foods and more sedentary in nature. The reduction in traditional, land-based food procurement and consumption among this population, given the known nutritional benefits of these foods and their importance to the holistic health of FN people, is of particular interest. Because of the high prevalence of food insecurity within on-reserve FN populations and the relative lack of economic opportunities in isolated and remote locations, these nutrient-rich traditional foods may sometimes be replaced with energy dense, nutrient poor store-bought alternatives. The food environment in many FN communities does not support or facilitate healthy choices. Healthy food may cost in excess of two times what it does in larger cities, and in remote and isolated locations, such foods may be inconsistently available and of unacceptable quality when they are. Access to traditional foods may be limited by high economic costs associated with their procurement, changes in the migratory patterns of traditional species, losses of traditional knowledge and fears of environmental contamination. If obesity and chronic disease are to be prevented in remote FN communities, children and adolescents are a logical target for population health interventions. In order to plan, initiate and evaluate program or policy initiatives, knowledge of the factors influencing the food intake of youth is necessary. Objectives. This thesis aimed to (a) review the current literature on the diets of Aboriginal youth in Canada, (b) explore the socioeconomic and sociocultural predictors of traditional food intake among a large nationwide sample of Canadian on-reserve FN youth, (c) explore the individual, behavioural and socioeconomic predictors of healthy store-bought food choices among a large nationwide sample of Canadian on-reserve FN youth, (d) assess the nutritional significance of traditional food consumption for youth in two remote, isolated FN communities in northern Ontario before and after a harvest sharing program, and (e) investigate the barriers and facilitators to the sustainability of a school-based healthy snack program for FN youth in a remote, isolated northern Ontario community and the impact of the program on diet. Methods. This thesis is presented as five individual studies. Study 1 presents a systematic literature review of refereed publications on the diets of school-aged Aboriginal youth residing in Canada, published between January 2004 and 2014. Using a predetermined search strategy, Medline (PubMed), Scopus, Education Resources Information Center, Web of Science and Google Scholar databases were scanned to identify the articles included. Each of the included articles was summarized for purpose, design, year, sample population, setting, dietary assessment method and main findings. Studies 2 and 3 utilized First Nations Regional Health Survey 2008/10 data, collected by the First Nations Information Governance Centre, to explore the individual, behavioural, socioeconomic and sociocultural predictors of traditional and store-bought food intake among 12-17 year-old youth living on reserves in Canada. Traditional and store-bought food intakes were elucidated via two separate food frequency questionnaires. The individual (i.e., age, sex, body mass index), behavioural (i.e., school attendance, physical activity, smoking, alcohol use), socioeconomic (i.e., number of children in the household, living with ones biological parents, parent education level) and sociocultural (i.e., use of a FN language, attending community cultural events, number of people helping to understand culture, food sharing) predictors of traditional food, milk and milk products, and vegetable intake were assessed via binary logistic regression modelling for four different age and sex subgroups. Studies 4 and 5 originated from longstanding research collaborations with the remote and isolated subarctic FN communities of the Mushkegowuk Territory on the western coast of James Bay in northern Ontario, Canada. Study 4 focused on two separate communities in which a harvest sharing program was initiated in May 2011 to support local access to lesser snow geese. Dietary data from grades 6-8 youth in both communities were collected via a validated web-based 24-hour dietary recall and food frequency questionnaire. The significance of snow goose consumption to food group and nutrient intake and the likelihood of achieving current dietary standards were assessed via Analysis of Variance and Pearson chi-square tests, where appropriate. Potential changes in diet from baseline to the post-pilot phase of the program were assessed via independent samples t-tests and Pearson chi-square tests. Study 5 focused on a healthy school snack program in one community, which was originally implemented in 2009 and previously evaluated for process and outcomes in 2010. The diets of grades 6-8 youth at baseline and at the four-year time point were assessed via a web-based 24-hour dietary recall, while qualitative information on the challenges and facilitators to the program’s sustainability were gathered via a focus group with the principal and coordinating committee. Possible changes in the food group and nutrient intakes of youth, as well as the proportion meeting current dietary standards were assessed via independent samples t-tests and Pearson chi-square tests. All quantitative analyses were conducted using Statistical Package for the Social Sciences (SPSS, v. 20 Complex Samples (Study 2 and Study 3) or v. 21 (Study 4 and Study 5), IBM Corporation, Armonk, New York) with a significance level of p≤0.05. Qualitative data were managed and analyzed inductively for themes by hand. The qualitative themes were substantiated by a second, independent researcher. Results. In Study 1, 24 studies were reviewed, all of which were cross sectional in design. The majority of studies (n=16, 67%) were from Ontario or Quebec, focused on FN youth (n=21, 88%) and took place in remote and/or isolated settings (n=18, 75%). Nearly all studies utilized the 24-hour recall approach to measure diet (n=19, 79%). On average, the diets of Aboriginal youth fall short of a number of important food groups and nutrients, with specific concerns for vegetables and fruit, milk and alternatives, fibre, folate, vitamin A, vitamin C, calcium and vitamin D across many studies, along with excess fast food and sugar sweetened beverage consumption. In Study 2, 31% of youth reported consuming traditional foods often (n=3587, representing a weighted population of 39 232, 50% 12-14 years old, 52% male). Frequent traditional food consumption was significantly associated with having a parent with a high school education (p=0.014), frequent participation in community cultural events (p<0.001), and often having traditional food shared with one’s household (p<0.001). For 12-14 year-old girls (n=834, weighted population of 9 451), the odds of consuming traditional foods often were increased for those who always or almost always participated in community cultural events as compared to those who rarely or never did (OR=2.43, CI=1.43-4.12, p<0.001), and those who often had traditional foods shared with their household as compared to those who had traditional foods shared with their household less often (OR=4.08, CI=2.26-7.34, p<0.001). For 15-17 year-old girls (n=960, weighted population of 9 376) there were increased odds of frequently consuming traditional foods for those who often had traditional foods shared with their household as compared to those who had foods shared with them less often (OR=4.61, CI=3.08-6.88, p<0.001). For 12-14 year-old boys (n=893, weighted population of 10 331), there were increased odds of frequently consuming traditional foods amongst those who spoke a FN language as compared to those who did not (OR=1.41, CI=1.01-1.96, p=0.024), those who always or almost always participated in community cultural events as compared to those who participated rarely or never (OR=1.76, CI=1.16-2.68, p=0.013), and those who often had traditional foods shared with their household as compared to those who had traditional foods shared with them less often (OR=5.13, CI=3.42-7.72, p<0.001). For boys aged 15-17 years (n=900, weighted population of 10 075), there were increased odds of often consuming traditional foods for those whose parents had a high school education as compared to those whose parents had not completed high school (OR=1.86, CI=1.17-2.95, p=0.024), those who always or almost always participated in community cultural events as compared to those who rarely or never did (OR=2.82, CI=1.63-4.88, p=0.001), and those who often had traditional food shared with their household as compared to those who had traditional food shared with them less often (OR=3.67, CI=2.54-5.30, p<0.001). With the exception of participation in community cultural events for 12-14 year-old boys, all of these relationships persisted following adjustment for other socioeconomic and sociocultural variables included in the multivariate models. In Study 3, more than two-thirds (68%) of participants reported eating vegetables at least daily (n=3721, representing a weighted population of 41 499, 52% male, 50% 12-14 years old) and over half (57%) reported consuming milk and milk products at least once per day (n=3717, representing a weighted population of 41 368, 52% male, 51% 12-14 years old). Daily vegetable consumption was associated with being younger (p<0.001), being physically active (p<0.001), being a non-smoker (p<0.001), abstaining from alcohol (p<0.001) and having at least one parent with a post-secondary education (p=0.026). For 12-14 year-old girls (n=891, weighted population of 9 968), the odds of eating vegetables at least daily were increased amongst those who were physically active as compared to those who were not (OR=1.80, CI=1.18-2.75, p=0.006) and those who did not use alcohol as compared to those who did (OR=1.70, CI=1.16-2.50, p=0.006). For 15-17 year-old girls (n=995, weighted population of 10 076), the odds of consuming vegetables daily were increased amongst those who did not smoke as compared to daily or occasional smokers (OR=1.61, CI=1.14-1.07, p=0.006). These relationships all persisted in the multivariate models. For 12-14 year-old boys (n=921, weighted population of 10 971), the odds of eating vegetables daily were increased amongst those whose parents had a post-secondary education as compared to those whose parents had not completed high school (OR=1.51, CI=1.00-2.28, p=0.050) and decreased amongst those who did not attend school as compared to those who did (OR=0.50, CI=0.26-0.95, p=0.031). For 15-17 year-old boys (n=914, weighted population of 10 484), the odds of eating vegetables daily were increased amongst those whose parents had a post-secondary education as compared to those who had not attended high school (OR=1.87, CI=1.16-3.01, p=0.033). These relationships did not persist when adjusted for other factors in the multivariate models. In this same study, milk and milk products consumption was associated with being female (p=0.025), attending school (p<0.001) and being a non-smoker (p<0.001). For 12-14 year-old girls (n=893, weighted population of 9 989), there were increased odds of consuming milk and milk products daily amongst those who did not smoke as compared to daily and occasional smokers (OR=1.93, CI=1.27-2.93, p=0.002) as well as amongst those who did not drink alcohol as compared to those who did (OR=1.67, CI=1.10-2.54, p=0.014). For 15-17 year-old girls (n=996, weighted population of 10 070), the odds of consuming milk and milk products daily were increased amongst those who were physically active as compared to those who were not (OR=1.64, CI=1.18-2.28, p=0.003), amongst those who were non-smokers as compared to those who smoked daily or occasionally (OR=1.56, CI=1.12-2.14, p=0.007) and amongst those who lived with one biological parent as compared to those who lived with neither biological parent (OR=1.91, CI=1.25-2.93, p=0.007). With the exception of the association between milk product intake and alcohol use amongst the younger sub-group of girls, all of these relationships persisted when controlled for the other variables included in the multivariate models. For 12-14 year-old boys (n=917, weighted population of 10 947), the odds of consuming milk and milk products daily were increased amongst those who were physically active as compared to those who were not (OR=1.51, CI=1.09-2.11, p=0.013) and decreased amongst those who lived with less than three children in their household as compared to those with greater than three children in their household (OR=0.68, CI=0.48-0.97, p=0.029) as well as those who did not attend school as compared to those who did (OR=0.20, CI=0.11-0.37, p<0.001). For 15-17 year-old boys (n=911, weighted population of 10 362), the odds of consuming milk and milk products daily were increased amongst non-smokers as compared to daily and occasional smokers (OR=1.81, CI=1.23-2.69, p=0.003) and decreased amongst those who did not attend school as compared to those who did (OR=0.40, CI=0.25-0.66, p=<0.001). All of these relationships persisted when adjusted for other variables included in the multivariate models. In Study 4 (n=84, 12.38±1.07 years old, 49% male, 67% overweight or obese), 39% of youth were found to consume snow goose weekly, and girls less so than boys (p=0.006). Although snow goose consumption was not associated with body mass index, the frequency of its consumption was associated with intake of meat and alternatives (p=0.019), protein (p=0.004), vitamin B12 (p=0.004), iron (p=0.011) and zinc (p=0.006), where nutrient intakes were highest among those who consumed snow goose moderately (2-6 times per week). Nutrient intake by goose consumption level interacted with sex for protein (p=0.018), thiamine (p=0.008), riboflavin (p=0.042) and iron (p=0.030). Although no changes in mean food group or nutrient intake intakes were observed following the harvest sharing program (n=73, 12.34±0.99 years old, 44% male), it appeared that a greater proportion of youth reported consuming snow goose at this time (63% vs. 48%), and girls were significantly more likely to report consuming the food (61% vs. 33%, p=0.015). In Study 5, youth had higher intakes of vegetables and fruit (p=0.048), milk and alternatives (p=0.017), ‘other’ foods (p=0.030), carbohydrates (p=0.025), fibre (p=0.019), thiamine (p=0.040), riboflavin (p=0.008), folate (p=0.006), calcium (p=0.015), iron (p=0.046), potassium (p=0.007), zinc (p=0.042) and kilocalories (p=0.021) following four years of the program (n=49, 12.7±1.0 years old, 59% male) as compared to baseline (n=43, 13.1±0.9 years old, 60% male). Although numerous challenges were encountered over the first four years of the program, many supporting strategies were noted by the principal and coordinating committee (n=3). Advocacy and community ownership of the program emerged as strong supports to the program’s expansion and sustainability. Acquiring reliable personnel and sustained funding, building new facilities and receiving donations of equipment, and moving away from local food purchasing were helpful approaches. Conclusions. The diets of Aboriginal Canadian youth of school age are typically energy dense and nutrient poor. Explorations of the individual, behavioural, socioeconomic and sociocultural predictors of traditional and healthy store-bought food intakes in a nationwide sample of on-reserve FN youth found a range of significant associations. Traditional food intake was strongly predicted by food sharing and closeness to one’s culture (i.e., participation in community cultural events and speaking a FN language), while the intake of healthy store-bought alternatives (i.e., vegetables, and milk and milk products) was predicted by school attendance, other health-related behaviours (i.e., not smoking, abstaining from alcohol, being physically active), and indicators of socioeconomic status (i.e., higher parent education level, fewer children residing in the household, living with both biological parents). These associations varied by age and sex and were not always in the expected direction. In three remote, isolated communities on the western coast of James Bay, school and community programs had a positive impact on the traditional food, healthy food and nutrient intakes of youth, but in all cases these programs were not sufficient to bring the micronutrient and food group intakes of these youth to recommended levels. Nevertheless, these investigations underscore the positive outcomes that can be achieved when the necessary resources are applied in communities that strongly value the good health of their young people.
Obesity, Physical Activity and Sedentary Behaviour Among Canadian First Nations Youth: An Exploration of Associated Factors and Evaluation of a School Sports Program
(University of Waterloo, 2016-01-19) Gates, Michelle
Background: Secondary to inequities in several determinants of health, Canadian Aboriginal youth are affected by a higher prevalence rate of obesity and chronic disease than the general population. While the factors contributing to obesity have been extensively studied among the general population, relatively little data are available for First Nations [FN] youth living on reserve. This dissertation will focus on two risk factors, physical inactivity and sedentary behaviour, amenable to change via community-level health promotion initiatives. Purpose: To (a) review quantitative evidence on physical activity [PA], fitness and sedentary behaviour among Canadian Aboriginal youth, (b) explore the potential relationships of socioeconomic, cultural and health behavioural factors with overweight/obesity among FN youth living on reserve, (c) explore the potential relationships of socioeconomic, cultural and health-related factors with high (>1.5 hours/day) levels of television viewing among FN youth living on reserve, (d) conduct a needs assessment for PA programming in one subarctic Ontario FN, and (e) evaluate the implementation and outcomes of a school sport program in this community. Methods: In Study 1, a systematic review of peer-reviewed quantitative research on the PA and fitness of Canadian Aboriginal youth was conducted. The studies, which also described sedentary behaviours, were summarized and the results were presented according to adherence to Canadian guidelines, age and sex differences, and associations with health outcomes. Studies 2 and 3 used data collected for the 12-17 year old subset of the 2008-2010 First Nations Regional Health Survey [RHS]. The relationships between a number of independent variables and (a) overweight/obesity or (b) high television viewing were assessed using logistic regression, stratified by age and sex. Analyses were weighted to account for the sampling strategy. Studies 4 and 5 responded to a subarctic Ontario FN community’s desire for school-based sport programming. A participatory, utilization-focused approach to program evaluation was employed in first conducting a needs assessment for PA and sport in the community (Study 4). Anthropometrics (body mass index [BMI], waist circumference, body fat percentage), PA (3 days of accelerometry) and physical fitness (informed by the Canadian Physical Activity, Fitness and Lifestyles Approach) were measured. Descriptive statistics were compared to reference data and group-level differences (by BMI, waist circumference and body fat status) were tested using Mann-Whitney U and Chi-square tests. Barriers and supports were assessed qualitatively. In Study 5, implementation and outcome evaluations for a school sports program were conducted by repeating the quantitative measures used in Study 4. Changes in these variables were tested using bootstrapped paired samples t-tests. Information on participation, satisfaction and program implementation was collected qualitatively. The qualitative data from Studies 4 and 5 were analyzed inductively for themes by hand, and verified by a second researcher. Results: The systematic review in Study 1 revealed 23 records, 35% (n=8) of which reported on national survey data and 65% (n=15) that reported regional data from several FN sub-populations. National reports showed that about half of youth are ‘active’ and up to two-thirds spend more than 15 hours per week in screen-based sedentary time. Results from regional reports were highly variable. Cardiorespiratory endurance was the only measure of fitness reported in regional studies, and generally appeared low. Girls were almost universally less active than boys. Physical activity was associated with a number of health outcomes; most commonly, an inverse association with BMI or reduced odds of obesity at higher PA levels were reported. Study 2 showed that among 12-17 year old FN youth living on reserve (n=2 888, representing 29 988 individuals in the weighted sample, 56.4% male), overweight/obesity (45.2% prevalence) was associated with younger age (p=0.024), knowledge of a FN language (p=0.015), lower PA level (p=0.001) and lower levels of video game use (p=0.042). Numerous age- and sex-based interactions prompted stratifying the sample for further analysis. No significant relationships were detected for boys aged 12-14 years. Among girls aged 12-14 years, reduced odds of overweight/obesity were observed among those who were moderately active (OR=0.48, 95% CI=0.26, 0.88) or active (OR=0.56, 95% CI=0.32, 0.96) as compared to inactive (p=0.048), and among those who spent more than 1.5 hours using a computer per day (OR=0.66, 95% CI=0.45, 0.96) as compared to those with lesser use (p=0.028). Among boys aged 15-17 years the odds of overweight/obesity were increased among those with parents in the middle education level (high school diploma; OR=1.78, 95% CI=1.15, 2.76) as compared to the lowest level (p=0.032), and those who always or almost always participated in their community’s cultural events (OR=2.06, 95% CI=1.23, 3.44) as compared to less frequent participation (p=0.005). The odds of overweight/obesity were reduced among those playing more than 1.5 hours of video games per day (OR=0.69, 95% CI=0.47, 0.99) as compared to those with lesser use (p=0.044). Among girls aged 15-17 years, the odds of overweight/obesity were increased among those with knowledge of a FN language (OR=1.67, 95% CI=1.15, 2.42) as compared to those without (p=0.007). The odds of overweight/obesity were reduced for those playing more than 1.5 hours of video games per day (OR=0.43, 95% CI=0.27, 0.67) as compared to those with lesser use (p=0.009), and those who reported sometimes (OR=0.43, 95% CI=0.27, 0.67) or always (OR=0.51, 95% CI=0.30, 0.87) eating a nutritious diet as compared to those reporting rarely or never (p=0.001). In all cases, the bivariate relationships remained significant in the multivariate adjusted analyses. Study 3 showed that among on-reserve FN youth (n=3 658, representing 40 462 individuals in the weighted sample, 53.1% male), 39.9% watched more than 1.5 hours of television daily. For the group, only attendance at community cultural events was associated with high television viewing (p=0.005). No significant effects of the tested independent variables were detected for younger (12-14 year old) youth. Among boys aged 15-17 years the odds of high television watching were increased among those with parents having a higher education level (OR=1.73, 95% CI=1.11, 2.69 for high school diploma; OR=1.74, 95% CI=1.16, 2.60 for post-secondary education) as compared to the lowest level (p=0.010), those who always or almost always participated in their community’s cultural events (OR=1.84, 95% CI=1.23, 2.75) as compared to less frequent participation (p=0.003), and those who were overweight or obese (OR=1.44, 95% CI=1.04, 2.00) as compared to normal weight (p=0.028). Among 15-17 year old girls the odds of high television viewing were reduced among those in the largest household size (OR=0.64, 95% CI=0.46, 0.89) as compared to the smallest size (p=0.030), and those reporting very good or excellent mental health (OR=0.63, 95% CI=0.45, 0.86) as compared to poorer mental health (p=0.004). The community needs assessment in Study 4 revealed that in a subarctic Ontario FN, 63% of participating youth in grades 6-7 (n=72, 61.1% male) were overweight or obese, 51% were abdominally obese and 21% had excess body fat. Meanwhile, 86% met Canadian PA guidelines. Cardiorespiratory endurance appeared low in comparison to Canadian Health Measures Survey findings for the general population. Those who were overweight, obese, and/or abdominally obese had lower cardiorespiratory endurance than other youth (p<0.001). Barriers and supports to youth PA fell under the themes of motivation, role modelling, personnel and facilities, and environment and programs. The findings informed a locally implemented school sports program. In Study 5, after a 9-months (one school year) of the program, 57 youth (12.8±1.0 years, 59.6% male) provided at least one of the process and outcome evaluation measures. Over the course of the program, youth increased their mean participation in moderate-to-vigorous PA by 47.9 minutes/day (p=0.016). Boys completed an average additional 10.5 shuttle run stages (p=0.006), and showed a non-significant trend toward improved cardiorespiratory endurance (p=0.057). Girls did not experience significant improvement in cardiorespiratory endurance. Both boys (+8.2 kg, p=0.002) and girls (+5.6 kg, p=0.012) improved their muscular strength. Flexibility improved for the group (+2.2 cm, p=0.015). Boys appeared to participate in the program more often than girls (not statistically significant); 28% of boys reported daily participation as compared to 15% of girls. Qualitative findings revealed barriers to implementation that were related to resource and infrastructure limitations. These were somewhat overcome by mobilizing of the few available resources and volunteer personnel. Conclusions: Many Canadian Aboriginal youth fail to meet established PA and sedentary behaviour guidelines, and physical fitness appears low among a few FN populations. Available data support an inverse association for both higher amounts of PA and lesser time in sedentary behaviour relative to overweight and obesity, providing impetus for PA programming in vulnerable communities. Data from the RHS showed that among FN youth living on reserve, overweight/obesity and high levels of television viewing are prevalent across all age and sex groups. The identification of several factors affecting the odds of overweight/obesity and television viewing has provided some evidence that may inform health promotion initiatives, however more research is needed to fully understand the observed relationships. The findings suggest that programming will need to be tailored to various and and sex categories. In a remote, northern Ontario FN community, although the majority of youth met Canadian PA guidelines, low physical fitness (particularly cardiorespiratory endurance) and a high prevalence of obesity and abdominal obesity supported the community’s desire for school-based PA programming. In the same community, many pre-existing barriers were overcome to implement a school sports program, which was well received. The program was associated with positive outcomes, more so among boys. Thus, future programming should target the participation of girls specifically. Nonetheless, this work demonstrates the many beneficial outcomes that can be achieved when a community with relatively few pre-existing resources is empowered to implement local, sustainable programming supporting the health of their youth.

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