The Nutrition Transition and the Double Burden of Malnutrition in Canadian Indigenous Peoples

The ‘double burden of malnutrition’ is a public health problem that is commonly observed in low and middle income countries. The double burden of malnutrition is when obesity and chronic, diet-related disease coexists with undernutrition, either within an individual, household or population (WHO, 2017). This trend is particularly apparent in Indigenous populations around the world who have been experiencing a westernization of traditional diets and lifestyles (Damman et al., 2008). In the Canadian Indigenous population, this trend has been well established by epidemiological research, especially among isolated communities in the arctic and subarctic regions of Canada. The double burden of malnutrition is associated with ‘the nutrition transition’. In the context of Canadian Indigenous peoples, this transition refers to the decreased consumption of traditional foods and an increased reliance on processed, nutrient-poor market foods which results in undernutrition and chronic diet-related disease (Kuhnlein et al., 2004). 

The cause of this dietary shift is complex and multifaceted. One of the key contributing factors to the nutrition transition is the changes in traditional food access. 'Traditional food' refers to food that is culturally significant and locally harvested from the environment by hunter-gatherer methods (Kuhnlein et al., 2004). In the Canadian arctic, moose, caribou, seal, birds, fish and other marine mammals are examples of traditional foods commonly consumed by Dene/ Métis, Yukon First Nations and Inuit communities (Kuhnlein et al., 2004). Traditional food is known to be much more nutrient dense, particularly in vitamins and minerals, than market foods and is associated with higher intakes of protein, Vitamin D and E, riboflavin, vitamin B6, iron, zinc, copper magnesium, manganese and potassium (ANN, 2012). Over the past few decades, traditional food consumption has been decreasing due to multiple factors such as lack of hunters, changing migratory patterns of game due to climate change and a lack of availability of refrigerator or freezer storage (ANN, 2012). One of the most concerning factors affecting traditional food use is climate change and environmental contamination. Bioaccumulation of organic pollutants and heavy metals in fish and other artic meat is a serious potential health threat, especially for pregnant women, and may therefore pose a major challenge to traditional food access.

Figure 1. Hunting and fishing are central to Indigenous culture and provide a good source of nutrients. Picture shows seal hunting in Diana Bay, Nunavik, Canada. Picture by M. Little, October 2018.

At the root of the problem is the prevalence of poverty and food insecurity. Canadian Indigenous peoples are disproportionately more food insecure than the general population, with the Inuit experiencing the highest prevalence of food insecurity of all North American Indigenous peoples (Egeland, Johnson-down, Cao, Sheikh, & Weiler, 2011). A health survey reported that in Nunavut Territory, 70% of Inuit preschoolers reside in food insecure households, of which 25% are severely food insecure (ANN, 2012). In Nunavut households, food insecurity is seven times higher and child food insecurity is ten times higher than that of provincial households (Egeland et al., 2011). Indigenous peoples in North America also experience more poverty than the general population, which is a determinant of health that is often associated with poor nutrition, obesity and diet-related disease. Indigenous households are unable to achieve adequate nutrition from store-bought foods due to unaffordability and limited availability. Market foods are not only nutritionally inferior to traditional food but are double the price in the Canadian arctic than in Southern Canada due to transportation costs. In these remote communities, perishability limits the availability and variety of fresh fruits and vegetables available in stores. When fresh produce is available, high cost and poor quality further hinder accessibility. Thus, lower-cost and low quality market foods are consumed to supplement the diet, especially when traditional food is unavailable. This increased reliance on processed ‘junk foods’ and drinks which are high in sugar, sodium and refined carbohydrates increases vulnerability to diet-related disease and malnutrition. This risk is even higher for children and youth who consume less traditional food than older generations and are more likely to develop chronic disease and obesity (ANN, 2012). 

Figure 2. Arctic sculpin fish caught in Diana Bay, Nunavik, Canada. Picture by M. Little, October 2018.

Without access to market foods of adequate nutritional quality such as meat, vegetables, low-fat dairy products and whole grains, the micronutrients that are otherwise obtained from traditional food (meat, fish, organs) are missing from the diet (Kuhnlein et al., 2004). Currently, Indigenous children are at an increased risk of developing anemia and rickets due to inadequate intake of iron, calcium and vitamin D (ANN, 2012). On the other hand, excess intake of certain nutrients induces obesity and metabolic syndrome. Prevalence of diabetes, cardiovascular disease and obesity are currently 2-3 times higher among the Canadian Indigenous population than the general Canadian population (ANN, 2012). A study reported a 5-fold increase in risk of mortality from diabetes in Indigenous women who live on reserves than the national average (Young, Reading, Elias, & Neil, 2000). In general, the health status of Indigenous Canadians is below that of the general population for most measures of health and evidence suggests that many of these health issues are related to diet (Willows, 2005). This burden is associated with the disproportionately high prevalence of poverty and food insecurity in indigenous communities and is impacted by urbanization, climate change and environmental contamination which contribute to the nutrition transition. If these health disparities are to be improved and positive nutritional status is to be achieved in face of declining traditional food use, there must be a variety of affordable, high-quality alternative foods available (Willows, 2005). Furthermore, the economic circumstances in Indigenous communities must be addressed to help alleviate poverty and food insecurity.

Traditional food and associated practices are integral to Indigenous cultural identity and is a significant part of their livelihoods (Damman et al., 2008). The ability to hunt, fish and access traditional foods is therefore an important determinant of Indigenous wellbeing. Under a human rights framework, the right to adequate food must therefore include the protection of traditional food access by the state to support Indigenous health (Damman et al., 2008). Moreover, government policies and programmes must consider the nutrition transition in order to mitigate the rise in chronic diet-related disease and increase availability and access to nutritious foods in Indigenous communities (Damman et al., 2008).

References:

Dietitians of Canada, Aboriginal Nutrition Network (ANN) (2012). Registered Dietitians in Aboriginal Communities: Feeding Mind, Body and Spirit. Role Paper of the Dietitians of Canada, Aboriginal Nutrition Network. Retrieved from http://www.dietitians.ca/aboriginalnutrition

Damman, S., Eide, W. B., & Kuhnlein, H. V. (2008). Indigenous peoples’ nutrition transition in a right to food perspective. Food Policy, 33(2), 135-155. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0306919207000498

Egeland, G. M., Johnson-Down, L., Cao, Z. R., Sheikh, N., & Weiler, H. (2011). Food insecurity and nutrition transition combine to affect nutrient intakes in Canadian Arctic communities. The Journal of nutrition, 141(9), 1746-1753.Retrieved from: https://academic.oup.com/jn/article/141/9/1746/4630723

Hansen, J. C. (2000). Environmental contaminants and human health in the Arctic. Toxicology Letters, 112, 119-125.Retrieved from: https://www.sciencedirect.com/science/article/pii/S0378427499002039

Johnson-Down, L. M., & Egeland, G. M. (2012). How is nutrition transition affecting dietary adequacy in Eeyouch (Cree) adults of Northern Quebec, Canada?. Applied Physiology, Nutrition, and Metabolism, 38(3), 300-305. Retrieved from: https://www.nrcresearchpress.com/doi/full/10.1139/apnm-2012-0167

Kuhnlein, H. V., Receveur, O., Soueida, R., & Egeland, G. M. (2004). Arctic indigenous peoples experience the nutrition transition with changing dietary patterns and obesity. The Journal of nutrition, 134(6), 1447-1453.Retrieved from: https://academic.oup.com/jn/article/134/6/1447/4688754

Little, M. (Photographer). (2018). Arctic sculpin. [Digital image].

Little, M. (Photographer). (2018). Seal Hunting. [Digital image].

Sharma, S., De Roose, E., Cao, X., Pokiak, A., Gittelsohn, J., & Corriveau, A. (2009). Dietary intake in a population undergoing a rapid transition in diet and lifestyle: the Inuvialuit in the Northwest Territories of Arctic Canada. Canadian Journal of Public Health, 100(6), 442-448.Retrieved from: https://link.springer.com/article/10.1007/BF03404341

WHO. (2017). Double Burden of Malnutrition. Retrieved from https://www.who.int/nutrition/double-burden-malnutrition/en/

Willows, N. D. (2005). Determinants of healthy eating in Aboriginal peoples in Canada: the current state of knowledge and research gaps. Canadian Journal of Public Health/Revue Canadienne de Sante'e Publique, S32-S36. Retrieved from: https://www.jstor.org/stable/41994470?seq=1#page_scan_tab_contents

Young, T. K., Reading, J., & Elias, B. (2000). Type 2 diabetes mellitus in Canada’s First Nations: Status of an epidemic in progress. Cmaj, 163(5), 561-566. Retrieved from: http://www.cmaj.ca/content/163/5/561.short