Chapter 6: Diabetes in Canada: Facts and figures from a public health perspective – First Nations, Inuit, and Métis

Chapter 6 – Diabetes among First Nations, Inuit, and Métis populations

Introduction

Canada's Constitution Act of 1982 recognizes three distinct groups of Aboriginal people: First Nations, Inuit and Métis.1 Each group has a unique history, culture, local languages, and spiritual beliefs.2;3 Great diversity exists within and between each group. In the 2006 Census of Canada, 1,172,790 people identified themselves as Aboriginal; of them, 59.5% as First Nations (status and non-status Indiansi ), 33.2% as Métis, and 4.3% as Inuit. Together they accounted for 3.8% of the country's total population. These numbers likely underestimate the true population size by approximately 80,000 individuals. An estimated 40,115 individuals were not included because enumeration was not completed on 22 First Nations reserves and settlements, in addition to approximately 40,623 individuals who were missed due to incomplete enumeration in participating First Nations communities.5 The Aboriginal population is younger and growing more rapidly than the general Canadian population. Almost half (47.8%) of Aboriginal individuals were under 25 years of age during the census year, compared to less than a third (31.7%) of the non-Aboriginal population.

While diabetes was rare among the Aboriginal population in North America prior to 1940, the rates increased rapidly after 1950 and have now reached epidemic levels in some communities.^{Footnote 6Footnote 7} Higher rates of type 2 diabetes in children and youth and of gestational diabetes in females have also been observed. Moreover, earlier age at onset and high rates of complications amplify the problem within many First Nations and Métis communities.

Diabetes in First Nations, Inuit, and Métis populations shares common trends and similarities. However, due to the considerable degree of diversity that exists within and between each group, presenting aggregated figures of diabetes rates, risk factors and complications for these populations would be misleading in many instances. Moreover, no single data source provides these data at a national level. Consequently, this chapter provides information on diabetes rates, risk factors and complications among First Nations, Inuit and Métis populations in Canada by using findings from a variety of surveys and studies.

Limitations of diabetes surveillance in First Nations, Inuit, and Métis populations

Many data limitations exist for diabetes surveillance for First Nations, Inuit and Métis populations. For example, the inclusion of Aboriginal individuals in national surveys is limited by the geographic coverage of sampling, non-participation, incomplete enumeration of reserves, and exclusion of homeless people.8;9 Different survey and sampling methods as well as changes in the criteria for diagnosis of diabetes can also interfere with the comparison of survey results between populations and over time. Health administrative data (hospital records, physician billing databases, and provincial/territorial health insurance registries) are often used for diabetes surveillance in the general Canadian population. However, only a limited number of provincial and territorial databases contain Aboriginal identifiers, limiting their use for surveillance for this population. Although the 2006 Aboriginal Peoples Survey (APS) sample is larger, this report used 2009-2010 CCHS data to estimate the prevalence of risk factors among First Nations individuals living off-reserve, Inuit and Métis for comparability reasons and to focus on the most recent data available. The 2008-2010 First Nations Regional Longitudinal Health Survey (RHS) was used to present statistics on First Nations individuals living on-reserve. Box 6-1 provides more detailed information on the national data sources used in this chapter; different years of data, age groups, and geographic areas are used depending on the data source.

Box 6-1. National data sources on the health of First Nations, Inuit, and Métis populations

Diabetes prevalence

In the last two decades, studies of diabetes in these populations across the country have shown that crude prevalence rates range from 2.7% to 19%, with some prevalence estimates reaching up to 30% once age-standardized.^{Footnote 7Footnote 8Footnote 15Footnote 20} The most recent national survey data show that the proportion of the population reporting a diagnosis of diabetes was highest for First Nations individuals living on-reserve (aged 18 years and older: 15.3%), followed by First Nations individuals living off-reserve (aged 12 years and older: 8.7%). The Métis (aged 12 years and older: 5.8%) had a similar prevalence to the non-Aboriginal population (aged 12 years and older: 6.0%). The prevalence of diabetes in the Inuit population remained lower than in these other groups, at 4.3% (aged 15 years and older) (Table 6-1). However, it is important to account for the younger age structure in the First Nations, Inuit and Métis populations when comparing the prevalence of diabetes to that of the non-Aboriginal population. After adjusting for this difference in age structure, the prevalence of diabetes was 17.2% among First Nations individuals living on-reserve, 10.3% among First Nations individuals living off-reserve, and 7.3% among Métis. Although the crude prevalence of diabetes among Inuit has historically been well below the national average, after adjusting for the difference in age structure, the prevalence of diabetes among Inuit was comparable to the general Canadian population.^{Footnote 20}

Prevalence by age

As in the general population, the prevalence of diabetes increases with age in First Nations, Inuit and Métis populations, but it is generally diagnosed at a younger age.^{Footnote 19Footnote 21Footnote 22} Type 2 diabetes is more frequent among Aboriginal children and youth than among their non-Aboriginal counterparts.^{Footnote 23Footnote 25}

Prevalence by sex

Aboriginal females experience higher rates of gestational diabetes than non-Aboriginal females.^{Footnote 26Footnote 32} Studies have shown prevalence rates of gestational diabetes in the First Nations population that were almost three times higher than in the non-First Nations population.^{Footnote 26Footnote 30} Recent Canadian data showed a higher proportion of women diagnosed with gestational diabetes in First Nations (4.8%), Inuit (4.0%) and Métis (2.2%) populations than in the non-Aboriginal population (0.5%).^{Footnote 22}

Studies had suggested that the prevalence of diabetes is higher among Aboriginal females than males, the reverse of the gender pattern observed for diabetes prevalence in the general Canadian population.^{Footnote 6Footnote 11Footnote 12Footnote 33} For example, in the Métis settlements of Northern Alberta, the prevalence of self-reported diabetes among females was significantly different than that reported among males, with a prevalence rate of 7.8% compared to 6.1%, respectively.^{Footnote 34} Another study conducted in Saskatchewan has shown that, between 1980 and 2005, the age-standardized prevalence rates of diabetes among First Nations (both on- and off-reserve) females were higher than among their male counterparts.^{Footnote 17} Some studies, however, found that the difference in prevalence may no longer exist between Aboriginal females and males.^{Footnote 22Footnote 35}

Prevalence by region

Administrative health data have been used to examine the prevalence of diagnosed diabetes among First Nations individuals in several regions of Canada. In 2006/07, based on data from the CCDSS, the age-standardized prevalence of diagnosed diabetes among British Columbia First Nations residents (aged one year and older) was 6.7% , compared with 4.8% among other British Columbia residents.^{Footnote 19} In Alberta, between 1995 and 2007, the age- and sex-adjusted prevalence of diabetes was approximately twice as high among status individuals than in the general population,^{Footnote 36} while in Quebec the age-standardized prevalence rate of diagnosed diabetes among James Bay Cree adults (aged 20 years and older) reached 19.1% in 2001/02,^{Footnote 37} compared with 5.1% in the general population.^{Footnote 38}

Prevalence over time

Diabetes is one of the fastest growing diseases among the Aboriginal populations in Canada. While diabetes was not observed in the Aboriginal populations until the second half of the 1900s, today most Aboriginal populations report prevalence rates that exceed or are comparable to the prevalence rates seen in the non-Aboriginal population.^{Footnote 10Footnote 12Footnote 19} Between 2001/02 and 2006/07, the age-standardized prevalence of diagnosed diabetes in Canadians (aged one year and older) increased by 26.8% (Chapter 1, Prevalence over time), while between 2001 and 2006, the self-reported prevalence of the disease doubled among the Canadian Inuit population, from 2% to 4%.^{Footnote 20} The prevalence in the First Nations population also increased, although data sources give varying estimates of the rise for different study populations and time periods. For example, in British Columbia between 2002/03 and 2006/07, the prevalence of diabetes in the First Nations population increased by about 15.5% (aged one year and older, age-standardized),^{Footnote 19} while during a similar five year period (2001 to 2005) the prevalence of diabetes in the First Nations populations in Northern Quebec increased by approximately 36.4%, from 11.0% to 15.0% (aged 15 and older, crude rates).^{Footnote 39} As for the Métis population in Canada, the self-reported rate of diabetes among those aged 15 years and older was 5.9% in 2001 and 7.0% in 2006, representing an increase of 19%.^{Footnote 35Footnote 40}

Risk factors for diabetes

The rapid increase of diabetes in the First Nations, Inuit and Métis populations has been influenced by a variety of risk factors, including genetic, biological, environmental and lifestyle factors. The rapid socio-cultural, environmental and lifestyle changes seen in First Nations, Inuit and Métis populations in the last half century have had a tremendous impact on their health and have contributed significantly to the higher rates of diabetes and its complications.^{Footnote 6Footnote 17Footnote 41} Lifestyle factors such as diet, physical inactivity, overweight and obesity, and smoking are key risk factors for type 2 diabetes in First Nations, Inuit and Métis populations, as they are in the general population (Chapter 4).

Genetic risk factors

A genetic risk factor, called the "thrifty gene effect",^{Footnote 42} has been hypothesized to increase diabetes rates in the Aboriginal populations. The theory suggests that as a protective response to regular periods of starvation, individuals of Aboriginal descent are genetically predisposed to conserve calories.^{Footnote 6Footnote 42Footnote 44} Historically, this thrifty gene was beneficial because Aboriginal individuals lived hunter-gatherer lifestyles, and access to foods was not always constant. However, Aboriginal individuals are now purchasing and consuming processed foods that are higher in calories, saturated fats and simple sugars, which increase their risk of obesity and diabetes.^{Footnote 6Footnote 44Footnote 45} Specific gene variants of the "thrifty gene" found in Oji-Cree people of north-western Ontario have been associated with the early onset of type 2 diabetes.^{Footnote 43} However, this theory has since been questioned, and the debate concerning the relative importance of genetic versus other environmental factors associated with diabetes susceptibility continues.^{Footnote 46Footnote 47}

Biological risk factors

Unlike the pattern among the non-Aboriginal Canadian population, First Nations females have historically shown higher prevalence of diabetes than First Nations males.^{Footnote 11Footnote 33} This is thought to be because First Nations females have higher rates of obesity than First Nations males.^{Footnote 33} As previously noted, Aboriginal females also experience higher rates of gestational diabetes than non-Aboriginal females.^{Footnote 22Footnote 26Footnote 31} Although gestational diabetes typically resolves after pregnancy, it increases the risk of type 2 diabetes later in life and the risk of obesity among offspring, thereby increasing the risk of diabetes in successive generations.^{Footnote 48} Finally, although impaired glucose tolerance has not been surveyed extensively in the First Nations, Inuit, and Métis populations, some studies suggest that females have higher rates of impaired glucose tolerance than males in the First Nations population,^{Footnote 16Footnote 18} increasing their risk of developing diabetes and its complications, particularly cardiovascular disease.^{Footnote 33Footnote 49}

Environmental risk factors

Health and social conditions vary significantly between individuals living on-reserve versus off-reserve and in rural versus urban areas. Living in rural or remote areas can lead to reduced opportunities for education and employment, as well as reduced availability of a safe and healthy food supply.^{Footnote 50} All of these factors can have a negative effect on health. Additionally, people living in Aboriginal communities often have less access to health care services due to geographic and language barriers, as well as the cost and limited availability of culturally appropriate services.^{Footnote 48Footnote 51} These barriers can affect the distribution of type 2 diabetes in the population and reduce care and treatment available for the prevention of diabetes and its complications.^{Footnote 52}

As a result of changing environments, displacement, hunting and fishing costs or restrictions, and a loss of harvesting capabilities, fewer individuals now consume traditional foods, and physical activity has declined among the Aboriginal populations. Traditional First Nations, Inuit and Métis diets are based on a combination of foods which includes fish, shellfish, marine and land mammals, and game birds, as well as green and root vegetables, fruit and berries — food sources that provide a protective effect from diabetes. A rapid transition to energy-dense foods and away from the traditional hunting, gathering and fishing, combined with lower levels of physical activity, is likely associated with the dramatic increase in the rates of overweight and obesity in the Aboriginal populations in the last several decades.^{Footnote 53}

Lifestyle risk factors

Overweight and obesity

Overweight and obesity are common in First Nations individuals, Inuit and Métis (Table 6-2).^{Footnote 54Footnote 55} According to the Canadian BMI guidelines based on self-reported height and weight, estimates suggest that 74.4% of First Nations adults living on-reserve were overweight or obese (2008-2010, aged 18 years and older), as were 62.5% of First Nations individuals living off-reserve, 58.3% of Inuit and 60.8% of Métis (2009-2010, aged 18 years and older). This is a higher proportion than the 51.9% of the non-Aboriginal population who were overweight or obese according to self-reported height and weight (2009-2010, aged 18 years and older). The proportion of the non-Aboriginal population who reported being overweight is similar to the proportion reported by the Aboriginal populations. However, the proportion of respondents who reported being obese was significantly higher among First Nations individuals living on-reserve, First Nations individuals living off-reserve, Métis and Inuit.

Although BMI provides a standard measure of body weight for population comparisons, the BMI standards set by the WHO have been found to overestimate the prevalence of overweight and obesity for the Inuit population. Inuit tend to have different body dimensions than other populations worldwide, such as shorter legs and a shorter stature. A consideration of other proportions, such as a sitting height-to-standing height ratio, could improve the assessment of obesity among Inuit.^{Footnote 56Footnote 57}

Physical inactivity

Using 2008-2009 CCHS and 2008-2010 RHS data, the prevalence of physical inactivity during leisure time was estimated among First Nations individuals, Inuit and Métis. However, activities practiced more frequently in Aboriginal populations (such as hunting) were not part of the CCHS pre-determined list of physical activities.

First Nations individuals living on-reserve

Only 26.0% (95% CI: 24.5-27.5%) of First Nations adults aged 18 years and older living on-reserve reported undertaking sufficient physical activity during leisure time. Activities included walking, running, swimming, bicycle riding, fishing, berry picking or food gathering, hunting and trapping. Males were more likely than females to report sufficient physical activity.^{Footnote 12Footnote 58}

First Nations individuals living off-reserve

In 2009-2010, 51.8% (95% CI: 48.0-55.5%) of First Nations adults (aged 20 years and older) living off-reserve were physically inactive during leisure time. This is comparable to the 49.7% (95% CI: 49.2-50.3%) of non-Aboriginal adults (aged 20 years and older) who reported being inactive.^{Footnote 11}

Inuit

In 2009-2010, 59.6% (95% CI: 50.5-68.6%) of Inuit adults (aged 20 years and older) reported being physically inactive during their leisure time, a proportion that was higher than the level of inactivity among the non-Aboriginal population (49.7%).11 In 2004, a Nunavik study reported that 82% of Inuit adults did not meet the recommended levels of physical activity for substantial health benefits. Nearly a quarter (24%) of these adults (aged 18 years and older) reported a main occupation that required very little physical effort. They did not compensate by engaging in a higher level of leisure-time physical activity. More than half (59%) of young Nunavik Inuit (aged 15 to 17 years) were active less than once a week for at least six months of the year; only 14% were at the recommended activity level for this age group.^{Footnote 59}

Métis

In 2009-2010, 46.7% (95% CI: 42.8-50.6%) of Métis adults (aged 20 years and older) reported that they were inactive during their leisure time. This is comparable to the 49.7% of non-Aboriginal adults (aged 20 years and older) who reported being inactive.^{Footnote 11}

Unhealthy eating

Globally, the nutritional habits of indigenous people are changing. Among First Nations, Inuit and Métis populations in Canada, the transition from traditional to non-traditional diets began at different times, is occurring at varying speeds, is affecting different age groups, and is dependent on several factors (e.g. living in an urban or rural area). This transition, combined with the possible "thrifty gene effect", plays a role in increasing the rates of obesity and diabetes in the Aboriginal population. Today, most First Nations individuals, Inuit and Métis consume more high-sugar, high-fat, store-bought (processed) foods than traditionally gathered foods in their daily diet.^{Footnote 6Footnote 60Footnote 61} As in the non-Aboriginal population (Chapter 4), a diet high in sugar, fat, or processed foods has contributed to increased overweight, obesity and risk of diabetes. Similarly, daily consumption of vegetables and fruit was used as a proxy for healthy diet; however, when consumed, certain traditional foods can substitute vegetables and fruit to provide essential nutrients.

First Nations individuals living on-reserve

Among First Nations adults living on-reserve, only 30.6% (95% CI: 29.2-32.1%) reported "always" or "almost always" eating a nutritious, balanced diet. More than half of all First Nations adults living on-reserve (51.8%; 95% CI: 50.2-53.4%) reported that they "sometimes" eat a balanced and nutritious diet, while 17.6% (95% CI: 16.4-18.8%) reported that they "rarely" or "never" do. The proportion of adults who reported "always" or "almost always" eating a nutritious and balanced diet was lowest among those aged 18 to 29 years (21.9%; 95% CI: 19.5-24.5%) and highest among those aged 55 years and older (44.4%; 95% CI: 41.9-46.9%).^{Footnote 12} First Nations adults living in communities with fewer than 300 people are more likely to consume traditional foods than those in larger communities.^{Footnote 12Footnote 62}

First Nations individuals living off-reserve

Among First Nations adults (aged 20 years and older) living off-reserve, 63.6% (95% CI: 60.1-67.1%) ate less than the recommended five or more servings of vegetables and fruit per day. This is slightly higher than the 56.4% (95% CI: 55.8-57.0%) of non-Aboriginal adults who reported the same.^{Footnote 11}

Inuit

A traditional Inuit diet, including seal, whale, caribou, fish and berries, is rich in omega-3 acids and may offer protection against chronic diseases such as hypertension and diabetes.^{Footnote 59} Consumption of a traditional Inuit diet is believed to play a role in the lower cholesterol levels that have been historically observed in the Inuit population.^{Footnote 63} However, Inuit have also moved away from traditional eating habits over the past two decades towards more commercially produced, processed foods.^{Footnote 20Footnote 45Footnote 59} A study of Inuit living in Nunavik (Quebec) found that the consumption of non-traditional, imported foods from the south was more common in younger Inuit, whereas the proportion of calories obtained from traditional foods was higher in Inuit adults aged 50 years and older (28.3%) than in adults aged 18 to 29 years (11%).^{Footnote 59} In addition to low consumption of traditional foods, self-reported data also showed low consumption of vegetables and fruit in Inuit adults. In 2009-2010, at the national level, 78.4% (95% CI: 71.7-85.0%) of Inuit aged 20 years and older reported eating less than the recommended number of servings of vegetables and fruit per day.^{Footnote 11}

Métis

Traditionally, Métis consumed a diet based on local wild sea and land mammals, fowl, fish, berries and grains.^{Footnote 64} The decline in use of traditional food-gathering methods, such as hunting, fishing and harvesting, has resulted in a decrease in the consumption of these traditional foods and a decline in the health of many Métis. Consumption of vegetables and fruit on a daily basis was also found to be low in Métis. In 2009-2010, 61.2% (95% CI: 57.3-65.1%) of Métis aged 20 years and older reported eating less than the recommended number of servings of vegetables and fruit per day, comparable to the 56.4% of non-Aboriginal adults who reported the same.^{Footnote 11}

Tobacco smoking

In 2009-2010, the prevalence rates of smoking reported among the First Nations, Inuit and Métis adults aged 18 years and older were double the rates reported among the non-Aboriginal population. Indeed, daily tobacco smoking rates for First Nations individuals living on- and off-reserve, Inuit, and Métis were 2.2 to 2.8 times the rate among non-Aboriginal individuals (Table 6-3).

Complications associated with diabetes

First Nations individuals, Inuit and Métis are subject to higher rates of co-morbidities and complications from diabetes than the general Canadian population.^{Footnote 65} Complications of diabetes include cardiovascular disease, lower limb amputation, retinopathy, kidney disease, hypertension, and nervous system disorder (Chapter 2).^{Footnote 33} Complications in the Aboriginal populations are thought to be higher due to an earlier age of diabetes onset, a greater severity of the disease, reduced access to health services due to geographical barriers, and an increased number of risk factors for other chronic diseases.^{Footnote 6Footnote 33Footnote 65Footnote 66} Diabetes mortality rates among First Nations individuals, Inuit and Métis are also higher than for the general Canadian population.^{Footnote 36Footnote 67Footnote 68} Currently, the rate of complications in First Nations adults living off-reserve, Inuit and Métis has not been studied extensively; available data, obtained from the RHS, describes the situation of First Nations individuals living on-reserve.

In 2002-2003, 89% of First Nations adults living on-reserve reported one or more adverse health consequences (problems with feeling hands or feet, vision loss, poor circulation, problems with lower limbs, heart problems, impaired kidney function, and/or infection) related to their diabetes, and almost 25% reported four or more (Figure 6-1). More than one-quarter (28.6%) of First Nations adults living on-reserve with diabetes experienced activity limitations as a result of the disease.^{Footnote 62} In 2008-2010, consequences associated with diabetes remained prevalent in First Nations adults living on-reserve, with many reporting complications with their kidneys, blood circulation, and infections (Figure 6-2).

Figure 6-1. Prevalence of adverse complications among First Nations individuals on-reserve aged 18 years and older with self-reported diabetes, by number of complications, Canada, 2002-2003

Source: Public Health Agency of Canada (2011); using data from the 2002-2003 First Nations Regional Longitudinal Health Survey (Phase 1) (First Nations Information Governance Centre).

[Click to enlarge Figure 6-1]

Figure 6-2. Prevalence of adverse complications among First Nations individuals on-reserve aged 18 yearsand older with self-reported diabetes, Canada, 2008-2010

Source: Public Health Agency of Canada (2011); using data from the 2008-2010 First Nations Regional Longitudinal Health Survey (Phase 2) (First Nations Information Governance Centre).

[Click to enlarge Figure 6-2]

Health service utilization

Health services for First Nations, Inuit and Métis populations are delivered through various federal, provincial/territorial and Aboriginal-run programs. Despite the high rates of chronic diseases, primary health care utilization is lower among the Aboriginal populations than in the general population.^{Footnote 22 Footnote 48 Footnote 69} Lower utilization is partly due to limited geographical access to primary health services for Aboriginal individuals living in Northern or isolated communities. However, rates of hospitalization are higher among some Aboriginal individuals.^{Footnote 44 Footnote 51} For example, in 2000 in Western Canada (British Columbia, Alberta, Saskatchewan and Manitoba), the age-standardized hospital separation rate for diabetes was seven times higher in the First Nations population living on and off-reserve (780 hospital separations per 100,000 population) than in the general population (110 separations per 100,000 population).^{Footnote 70} The high rates of hospitalization, a measure of more acute serious health events, may be the result of limited access to primary and preventative health care^{Footnote 22 Footnote 51} and poorer day-to-day management of diabetes.

Direct costs of diabetes for First Nations individuals

Estimating the costs of diabetes is a challenging undertaking (Chapter 3, Economic costs of diabetes). Information is currently unavailable for all First Nations, Inuit and Métis individuals, but two reports — one based on data from Saskatchewan and the other on data from Manitoba — have tried to estimate the costs of care for First Nations individuals with diabetes who are registered under the Indian Act of Canada.^{Footnote 71 Footnote 72}

In Saskatchewan,^{Footnote 71} registered First Nations individuals with diabetes were more likely to visit a physician, to be hospitalized, or to receive dialysis when compared to the use of services by the general population with diabetes. The health care costs for First Nations individuals with diabetes were more than double those of First Nations individuals without the disease, and 40% higher than the costs for individuals with diabetes in the general population. Using a different methodology for calculating the excess costs of diabetes, the study in Manitoba^{Footnote 72} found that per capita health care costs for First Nations individuals with diabetes were 34% higher than for First Nations individuals without the disease, and 69% higher than for those with diabetes in the general population. However, neither analysis examined outpatient costs such as prescription drugs, devices, or transportation. If the general use of these resources differs from that of the general population, overall cost comparisons may be affected.

The Aboriginal Diabetes Initiative

In response to the high rates of diabetes and its risk factors in Aboriginal populations, the federal government launched the Aboriginal Diabetes Initiative (ADI) in 1999, as part of the Canadian Diabetes Strategy, with an initial funding of $58 million over five years. It was expanded in 2005, with a renewed budget of $190 million over five years. In 2010, the federal budget committed $275 million over five years to support the activities of the ADI.

The main objective of the ADI is to reduce type 2 diabetes through the support of health promotion and disease prevention activities and services, delivered by trained community diabetes workers and health service providers. Through the ADI, Health Canada works in partnership with Tribal Councils, First Nations communities and organizations, Inuit communities and groups, and provincial and territorial governments to support prevention, health promotion, screening and care management initiatives that are community-based and culturally appropriate.

Renewed funding (2010-2015) will enable First Nations and Inuit communities to continue to build on past successes in more than 600 First Nations and Inuit communities throughout Canada. The renewed ADI will feature several areas of enhanced focus, including:

• Initiatives for children, youth, parents and families;
• Diabetes in pre-pregnancy and pregnancy;
• Community-led food security plans to improve access to healthy foods, including traditional foods; and
• Enhanced training for home and community care nurses on clinical practice guidelines and chronic disease management strategies.

Using local knowledge, First Nations and Inuit communities are encouraged to develop innovative, culturally relevant approaches aimed at increasing community wellness and ultimately reducing the burden of type 2 diabetes. Community activities funded through the ADI vary from one community to another, and may include walking clubs, weight-loss groups, diabetes workshops, fitness classes, community kitchens, community gardens and healthy school food policies. The ADI also supports traditional activities, such as traditional food harvesting and preparation, canoeing, drumming, dancing, and traditional games.

Looking ahead

The rapid socio-cultural changes in the lives of First Nations individuals, Inuit and Métis in the last half century have had a tremendous impact on their health. In its report, the Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology highlighted that: "population level factors which determine the health and well being for any collectivity have their origins in upstream historic, cultural, social, economic and political forces affecting the lives of Aboriginal Peoples living in Canada."^{Footnote 52} The management of lifestyle risk factors, such as physical inactivity, unhealthy eating, and overweight and obesity, plays a key role in preventing diabetes and reducing complications. Community-based programs that reflect the distinct heritages, languages, cultural practices and spiritual beliefs of First Nations, Inuit and Métis populations are important for primary prevention, care and management of diabetes in these populations.

Reference list

1. Individuals in Canada registered under the Indian Act can be referred to as either Registered Indian or Status Indians.⁴ Both terms are used in this report.