Background
Approximately 30% of Inuit and 35% of Inuvialuit over the age of 15 years reported having at least one chronic health condition in 2008 [
1]. Additionally, about 57% of the population residing in the Northwest Territories is overweight or obese, compared to 54% of the national Canadian average [
2]. Overall, Indigenous people in Canada have a life expectancy 8 to 13 years lower than non-Indigenous Canadians [
3,
4], which may contribute to this populations’ relatively high health care costs (approximately 1.8-2.2 times the Canadian average) [
5].
The lifestyle and diet changes experienced by Indigenous peoples during the last decades influence diet quality, which affects the prevalence of nutrition-related chronic diseases (e.g. hypertension, diabetes, obesity, and some forms of cancer) in Canadian Indigenous populations residing in Nunavut (NU) and the Northwest Territories (NWT) [
6‐
10]. Several studies of Inuit and Inuvialuit populations have documented rapid socio-economic and cultural transitions related to acculturation which have ultimately led to a shift away from traditional diets and procurement practices towards increased dependence on non-nutrient-dense, store-bought foods [
10‐
13]. Populations residing in NU and the NWT are further challenged by their remote location [
13] and the increasing cost of food [
14], creating reliance on inexpensive non-perishable processed foods that are usually non-nutrient-dense [
15].
Recent assessments in Inuit and Inuvialuit adults found that dietary fiber, calcium, folate, and vitamins A and E (and vitamin D among women) were below the recommendations in 60-100% of participants [
16,
17]. In addition, recent studies found a high prevalence of preparation methods that add fat to foods (e.g. frying with lard) [
18,
19]; these preparation methods are determinants of fat intake [
20,
21] and risk factors for impaired glucose tolerance [
22] among Inuit and Inuvialuit populations.
Health promotion programs that concentrate on healthy eating for the reduction of chronic disease should use a comprehensive approach that combines individual, organizational and policy levels in order to effectively address the multilevel risk factors [
6]. Furthermore, store-based environmental interventions that integrate behavior change strategies have proven effective in improving diet with other Indigenous and low-income populations [
23‐
25]. Combined environmental and behavioral approaches have been shown to be one of the most promising ways to improve diet and reduce risk of chronic disease [
26].
Healthy Foods North (HFN) was an evidence-based intervention program designed specifically for Inuit and Inuvialuit populations to reduce the risk of chronic disease by improving diet and increasing physical activity. HFN combined behavioral and environmental strategies through community-based activities, multi-institutional partnerships, and point of purchase to increase the availability, accessibility and visibility of healthy foods as well as opportunities for physical activity. HFN was tailored to build on the strengths and meet the specific needs of the communities through culturally appropriate programming [
24,
27‐
29]. Key elements of HFN included the promotion of healthier food preparation methods, the multitude of benefits related to traditional foods, and healthier options in stores [
13,
28]. These traditions included food sharing, survival from the land and respect for food [
30].
The purpose of this study was to evaluate the 12 month HFN intervention program by: 1) determining pre- to post-intervention changes in grams/day and frequency of consumption of de-promoted (i.e., discouraged) food groups, such as store-bought high-fat meats and unhealthy drinks; and 2) comparing pre- and post-intervention changes in healthy and unhealthy preparation methods.
Results
A total of 441 QFFQs and 494 AIQs were collected at baseline; response rates ranged from 74-93% in NU and from 65-85% in the NWT communities. Only participants who completed both pre- and post-intervention QFFQs (n = 332), and pre- and post-intervention AIQs (n = 378) were included in the analyses. Table
2 describes the 15 most commonly used preparation methods for eight foods: bannock, chicken, pork or beef, Arctic char (fish), seal, muskox or caribou, potatoes, and eggs.
Table 2
Adult Impact Questionnaire (AIQ) (
Food preparation methods section)
Food | First most used methods | Second most used method | Cooking method options |
Bannock | | | 1 = Did not cook in last 30 days |
Chicken | | | 2 = Deep-fried in oil, lard, animal fat, or shortening |
Pork or beef | | | 3 = Pan fried in oil, lard, animal fat, or shortening |
Fish (Arctic char) | | | 4 = Pan fried in own fat or water |
Seal | | | 5 = Pan fried in own fat or water and drained |
Muskox or caribou | | | 6 = Pan fried in own fat, drained, and rinsed |
Potatoes | | | 7 = Cooked with cooking spray only |
Eggs | | | 8 = Microwaved, baked, roasted, broiled without added fat |
9 = Microwaved, baked, roasted, broiled with added fat |
10 = Grilled |
11 = Boiled, cooked with a slow cooker |
12 = Boiled and drained or skimmed |
13 = Steamed |
14 = Smoked |
15 = Raw (or frozen raw) |
16 = Dried |
17 = Other |
18 = No other method |
Now I am going to ask you about how your household usually prepares different foods.
-
Please think about how the foods listed here were cooked at home IN THE PAST 30 DAYS.
-
How did you most often cook [food name] (Method #1) in the past 30 days?
-
Now tell me how you next most often cooked [food name] (Method #2).
-
Please refer to Part 3 on the answer sheet for response choices.
Table
3 describes the demographic characteristics of Inuit/Inuvialuit men and women by intervention assignment. Compared to the control communities (n = 111), participants in the intervention communities (n = 221) were significantly older (
p = 0.01) and were less likely to have at least one household member on income support (
p = 0.03), but were similar in all other demographic variables.
Table 3
Characteristics of the study sample by intervention assignment
Age (years)
| 45.5 | 14.1 | 41.9 | 10.7 | 0.011
|
|
N
|
%
|
n
|
%
| |
Gender
| | | | | |
Men | 44 | 20 | 20 | 18 | |
Women | 177 | 80 | 91 | 82 | 0.682
|
Material Style of Life (MSL)
| | | | | |
Low (MSL score <8) | 64 | 30 | 28 | 25 | |
Intermediate (MSL score 8–12) | 77 | 36 | 35 | 32 | |
High (MSL score >12) | 73 | 34 | 47 | 43 | 0.312
|
Education
3
| | | | | |
Low | 81 | 38 | 46 | 42 | |
Intermediate | 87 | 41 | 39 | 36 | |
High | 45 | 21 | 24 | 22 | 0.662
|
Number of adults living in the household who receive income support
| | | | |
No | 56 | 26 | 24 | 22 | |
Yes | 159 | 74 | 85 | 78 | 0.032
|
People in household working
| | | | | |
No | 130 | 60 | 52 | 48 | |
Yes | 85 | 40 | 57 | 52 | 0.432
|
Changes in frequency (times/day), total intake (g/day) and portion sizes (g/day) of food intake between and within intervention and control groups are presented in Table
4. The frequency of high-fat meat consumption significantly decreased in the intervention communities (∆ = −0.2 times/day) and remained constant in the control communities. There was a significant decrease in the frequency of high-fat dairy product consumption in the intervention communities from 0.2 to 0.1 times/day (∆ = −0.1 times/day); in contrast, the frequency of high-fat dairy product consumption in the control communities increased from 0.1 to 0.2 times/day. The control communities had a significant increase in the frequency of refined grain product consumption (0.9 to 1.2 times/day) and unhealthy drinks (1.3 to 1.6 times/day). Within both treatment groups there was a significant increase in frequency of unhealthy additions intakes; however, the change was not statistically significant between intervention and control groups.
Table 4
Change in frequency, total intake and portion size of consumption of de-promoted food groups by intervention assignment among adult Inuit and Inuvialuit
Frequency (time/day)
| | | | | | | | | | | | | |
High-fat meats | 0.4 | 0.5 | 0.3 | 0.3 |
−0.2
†
| 0.4 | 0.3 | 0.3 | 0.3 | 0.4 | 0.0 | 0.4 |
−0.2
†
|
High-fat dairy products | 0.2 | 0.4 | 0.1 | 0.4 |
−0.1
*
| 0.5 | 0.1 | 0.3 | 0.2 | 0.4 |
0.1
*
| 0.5 |
−0.2
‡
|
Refined grain products | 0.8 | 0.7 | 0.9 | 0.8 | 0.0 | 0.8 | 0.9 | 0.6 | 1.2 | 1.0 |
0.3
†
| 1.0 |
−0.3*
|
Unhealthy drinks | 1.3 | 1.0 | 1.3 | 1.1 | 0.0 | 1.1 | 1.3 | 1.1 | 1.6 | 1.1 |
0.3
*
| 1.2 |
−0.3*
|
Unhealthy snacks | 0.3 | 0.5 | 0.3 | 0.4 | 0.0 | 0.4 | 0.3 | 0.4 | 0.3 | 0.3 | 0.0 | 0.4 | −0.0 |
Unhealthy additions | 2.0 | 1.5 | 2.3 | 1.5 |
0.3
*
| 1.4 | 2.0 | 1.4 | 2.4 | 1.5 |
0.4
‡
| 1.4 | −0.1 |
Total Intake (g/day)
| | | | | | | | | | | | | |
High-fat meats | 46 | 72 | 27 | 47 |
−19.0
†
| 66.8 | 24 | 24 | 33 | 73 | 8.9 | 69.6 |
−27.9
‡
|
High-fat dairy products | 19 | 88 | 11 | 41 | −8.0 | 91.3 | 6 | 17 | 18 | 52 |
11.8
*
| 50.7 |
−19.8*
|
Refined grain products | 69 | 67 | 69 | 77 | 0.7 | 85.9 | 110 | 127 | 112 | 132 | 2.3 | 150.5 | −1.6 |
Unhealthy drinks | 754 | 885 | 587 | 846 |
−166.6
*
| 808.2 | 727 | 785 | 749 | 966 | 21.9 | 1028.3 | −188.5 |
Unhealthy snacks
3
| 49 | 156 | 17 | 24 |
−31.5
*
| 153.9 | 36 | 70 | 17 | 21 |
−18.6
*
| 68.8 | −12.93
|
Unhealthy additions | 48 | 52 | 37 | 40 |
−11.1
‡
| 47.3 | 45 | 55 | 33 | 46 |
−12.1
*
| 53.8 | 0.9 |
Portion size (g/day)
| | | | | | | | | | | | | |
High-fat meats |
281
†
| 199 |
195
†
| 161 | −85.6 | 196.8 | 232 | 168 | 219 | 244 | −12.6 | 244.0 |
−73.0*
|
High-fat dairy products | 35 | 131 | 26 | 76 | −8.3 | 142.6 | 28 | 81 | 42 | 92 | 14 | 114.0 | −22.3 |
Refined grain products |
204*
| 136 |
178*
| 110 | −26.6 | 155.9 |
274‡ | 186 |
216‡ | 116 | −57.6 | 181.7 | 31.0 |
Unhealthy drinks |
944
†
| 829 |
723
†
| 615 | −221.2 | 703.7 |
946*
| 639 |
778*
| 511 | −168.4 | 625.9 | −52.8 |
Unhealthy snacks
3
|
106
†
| 129 |
58
†
| 41 | −48.3 | 127.7 |
138
†
| 109 |
65
†
| 36 | −73.8 | 116.6 | 25.5 |
Unhealthy additions |
56
†
| 52 |
42
†
| 48 | −13.9 | 49.7 |
56*
| 59 |
40*
| 50 | −16.3 | 54.3 | 2.4 |
Total intake of high-fat meat significantly decreased in the intervention group from 46 to 27 g/day and increased in the control group from 24 to 33 g/day (∆ = −27.9 g/day) but this was not significant statistically. Compared to the control group the portion size of high-fat meat intake decreased significantly in the intervention group (∆ = −73.0 g/day). The decrease in high-fat meats can, in part, be attributed to the significant change in processed beef or pork total intake within intervention groups (−16.8 g/day, data not shown). There was a non-significant decrease (19 to 11 g/day) in total intake of high-fat dairy products in the intervention communities, while intake significantly increased in the control communities from 6 to 18 g/day (∆ = −19.8 g/day). Unhealthy drinks significantly decreased within the intervention group from 754 to 587 g/day. Unhealthy snacks and additions significantly decreased within both the intervention and control groups, however there was no significant difference between the intervention and control groups (Table
4).
In fully adjusted ANCOVA analysis, receiving the intervention was significantly inversely associated with daily de-promoted grain intake (β = −26, 95% CI: −46, −6). A male gender was associated with a higher intake of high-fat meats (β = 20, 95% CI: 7, 33) and de-promoted grains (β = 42, 95% CI: 17, 67). Participants with the highest MSL score compared with the reference group had a lower de-promoted grain intake (β = −30, 95% CI: −57, −3). Every 10 year increase in age was associated to 112 grams of less de-promoted drink consumption (95% CI: −186, −39). People living in households with income support and/or family member employed had a lower intake of de-promoted additions than people without supports (β = −14, 95% CI: −24, −5).
Table
5 shows pre- to post-intervention changes for the most commonly used healthy and unhealthy food preparation methods between and within intervention assignment groups.
Table 5
Change in the most frequently reported preparation methods pre- and post- intervention by intervention assignment among adult Inuit and Inuvialuit
Unhealthy methods2
|
2.0
†
| 1.0 |
1.6
†
| 0.9 | 1.9 | 1.1 | 1.8 | 1.0 | −0.2 |
Healthy methods3
|
3.9‡ | 1.3 |
4.3‡ | 1.3 | 4.5 | 1.5 | 4.3 | 1.4 |
0.5‡ |
Select preparation methods
| | | | | | | | | |
Microwaved, baked, roasted, broiled (no added fat) 2
|
2.0*
| 1.6 |
2.2*
| 1.4 | 2.3 | 1.6 | 2.0 | 1.3 |
0.5*
|
Microwaved, baked, roasted, broiled (added fat) 2
|
0.7*
| 1.4 |
0.4*
| 0.7 |
0.1
†
| 0.4 |
0.4
†
| 0.7 |
−0.7
†
|
Deep fried in oil, lard, animal fat, or shortening2
|
0.3
†
| 0.7 |
0.1
†
| 0.3 |
0.9
†
| 1.4 |
0.2
†
| 0.4 |
0.5
†
|
Pan fried in oil, lard, animal fat, or shortening2
|
2.6‡ | 1.7 |
2.1‡ | 0.3 |
2.6* | 1.8 |
2.2* | 1.4 |
−0.1* |
Pan fried in own fat or water and drained; rinsed4
|
0.1*
| 0.3 |
0.2*
| 0.5 | 0.2 | 0.6 | 0.2 | 0.5 |
0.2* |
Raw (or frozen raw), dried4
|
0.7* | 0.9 |
0.8* | 0.9 | 0.8 | 1.0 | 0.7 | 0.8 | 0.2 |
Healthy preparation methods increased significantly in the intervention group from 3.9 to 4.3 times/day, and there was a significant pre- to post-intervention change between groups (∆ = 0.5 times/day). Unhealthy preparation methods decreased within the intervention group from 2.0 to 1.6 times/day (p ≤ 0.0001). Pre- to post-intervention changes between the intervention and control groups included: microwaved, baked, roasted, broiled with no added fat (∆ = 0.5 times/day, p ≤ 0.05); pan fried in own fat or water and drained (and/or rinsed) (∆ = 0.2, p ≤ 0.05); microwaved, baked, roasted, broiled with added fat (∆ = −0.7 times/day, p ≤ 0.0001); and pan fried in oil, lard, animal fat, or shortening (∆ = −0.1 times/day, p ≤ 0.05). The intervention group had a significant decrease in food preparation through deep frying in oil, lard, animal fat or shortening, but the control group had a greater decrease in this preparation method (∆ = 0.5, p ≤ 0.0001).
Discussion
Nutrition intervention programs may be beneficial for Inuit and Inuvialuit populations, which have an estimated threefold higher prevalence of heart disease compared to the Canadian national average [
19,
36] and increased risk factors for diabetes, obesity, and hypertension [
37]. It is well established that decreasing animal fats, including high-fat dairy products and partially hydrogenated fats, aids in the reduction and prevention of obesity and its related comorbidities [
38,
39]. Evidence also strongly supports an inverse relationship between the consumption of fruit and vegetables and risk of several cancers, heart disease, and overall mortality [
40]. This may be due to the naturally occurring essential nutrients (e.g. antioxidants, fiber, and folic acid) within fruit and vegetables [
38,
41]. Thus, the year-long pilot HFN intervention was designed in part to reduce reliance on high fat, high sugar, non-nutrient-dense foods and beverages and unhealthy preparation methods that added fat, and to increase utilization of healthier cooking methods, in an attempt to reduce chronic disease risk. The results of the intervention were successful in reducing the consumption of de-promoted foods and in the utilization of unhealthy cooking. There was a significant increase in the use of healthy preparation methods within 12 months. The pre-intervention evaluation of this population indicated that pan-frying with fat was one of the most frequently reported methods of preparation [
18,
19]. Post-intervention results from the intervention communities indicated a decrease in the use of this method and a concurrent increase in the use of pan-frying methods that did not add fat, thereby reducing added fat consumption in the population under intervention. Several epidemiological studies suggest that the consumption of fried, boiled or roasted red meat is associated with the development of cancer; it has been proposed that heterocyclic aromatic amines, potent mutagens present at ng/kg levels in cooked foods play an important role in the aetiology of human cancer [
42,
43]. Therefore, avoiding high-temperature cooking methods may lower the risk of cancer.
Compared to the control group, the intervention group had a greater reduction in intake of de-promoted high-fat meats, high-fat dairy, refined grain products, and unhealthy drinks, all of which are commonly consumed food groups in this population [
11,
12,
27,
29]. Baseline studies determined that sweetened juices/drinks made the largest contribution to energy, carbohydrate, and sugar in NU and the first and second largest contribution in the NWT. Regular soft drinks and white bread were also top contributors to energy, carbohydrate, and sugar for both populations. Furthermore, butter, margarine, lard, and high-fat meats, including sausages and lunchmeats, were the top contributors to fat [
16,
17,
27,
29]. The reduced consumption of de-promoted food groups (particularly refined grains, unhealthy drinks, high-fat dairy products and high-fat meats) in the intervention group compared to control could explain the decreases in energy intake (average of 317 kcal/day), protein intake (21 g/day), carbohydrate intake (37 g/day), and overall Body Mass Index (BMI) (p = 0.002) [
44]. Improved intake of vitamin A and D were also observed. These nutrients are naturally abundant in the traditional foods consumed by Arctic Indigenous populations [
10,
13,
45]. Therefore, it may be inferred that dietary adequacy improved, in part, as a result of the observed significant increase in traditional food intake (from 1.4 to 1.7 times/day within the intervention group).
To our knowledge, there have been no studies on the impact of interventions within Inuit/Inuvialuit populations; therefore, the effectiveness of HFN’s community-based program must be compared with interventions targeting other Indigenous and/or remote populations. A recent review on the community-based interventions in prepared-food sources found some promising results however the outcome measures were limited [
46]. Many of the interventions included in this review were not formal studies but rather certification or campaign programs operated by local health departments. Therefore, the voluntary nature of the programs may explain why they varied in levels of reach. Similar to the present study, a store-based intervention targeting Native American adults living on Arizona reservations saw no change in the consumption of high-sugar, high-fat snacks and fast food. They found that the consumption of the comparison group increased significantly for less healthy foods over the year of the intervention program, which may indicate that in general, people are eating less healthy. It is possible that the program helped keep the intervention group’s diets from getting unhealthier [
47].
A family-based intervention conducted with the Six Nations Reserve in Ohsweken, Ontario made similar observations [
48]. They reported a decrease in intake of fatty foods, oils, and sodas paralleling HFN’s decrease in high-fat meat consumption, unhealthy drinks, and unhealthy cooking methods. However, some interventions among Indigenous populations outside of North America have shown promising results. Promotion of local foods and a traditional diet have resulted in increased intake of local accessible foods as well as increased nutrient intake in Indigenous populations in Micronesia [
45], the Dalit in India [
49], and Australia [
50].
HFN was a community-based and community-driven intervention project. Community interventions have much greater potential to reduce weight and related health risks than individual weight loss programs [
48,
51]. There is greater possibility for sustainability if the programs partner with community-based institutions such as schools and stores [
52]. However, it is important to consider the remoteness of these Arctic populations and the economic and environmental barriers that limit the feasibility of an active lifestyle and access to fresh nutritious foods. Future program development should focus on mitigating these barriers by improving the accessibility and affordability of healthy foods (e.g. fruit and vegetables and low-fat, low-sugar store bought items); furthermore, traditional foods high in protein, iron, and vitamins should be promoted [
10,
16,
17,
53]. Marine omega-3 fatty acids, contained in Arctic char and other fish and marine mammals, have proven protective effects against coronary heart disease in several diverse populations [
54]. Continued efforts to revitalize traditional food systems, such as hunting, gathering, and food-sharing, are equally important as they have a multitude of health and well-being benefits. Ongoing trials with longer intervention periods and larger sample populations are needed to monitor HFN’s impact on chronic disease risk.
Strengths and limitations
The sample was predominantly female (80-82%) because the study targeted the primary food shoppers and preparers. Bias may also have been introduced by the lower response rates that were observed for some communities. Given the potential for variation in access to store bought and traditional foods throughout the year, differences in the time of year for collection of baseline and follow up data, particularly for the NWT communities, may also have led to bias. In addition, limited data were available for potential confounders. However, baseline dietary differences between control and intervention groups were unchanged when stratified analyses were examined for age and income support (variables that were differentially distributed among the control and intervention groups). It is unlikely that the control groups were exposed to the intervention content that was disseminated via television and radio, as access to media between communities is limited in this remote region. Therefore, results may not be generalizable to male Inuit and Inuvialuit populations. Recall bias, which may occur with QFFQs, is another potential limitation [
55]. However, validation studies of the QFFQs used in this study confirmed relative agreement with multiple 24-hour recalls in this population [
33,
34].
This study provides the first data on the impact of a multi-institutional, community-based nutrition intervention program among Inuit in NU and Inuvialuit in the NWT. These data will contribute not only to the limited literature, but may also contribute to government policy decision-making related to Inuit and Inuvialuit nutrition and health. The data collection instruments are current and culturally relevant for this population.
Acknowledgments
We would like to thank all participants in the communities where the research was conducted. We also would like to thank the communities, the NorthWest Company, Arctic Co-operatives Limited, Stanton’s, and local store managers and shops for their support and participation. We would especially like to express our gratitude to all of the individuals whose help, generosity, and dedication has made this research possible; Dr. Andrew Applejohn, the Aurora Research Institute, Ms. Audra Donnison, Ms. Annie Buchan, Ms. Rahabi Kamookak, Ms. Julia Ogina, Ms. Nora Niptanatiak, Ms. Rhonda Reid, Mr. James Howard, Ms. Sarah Reaburn, Ms. Anita Pokiak, Ms. Melanie Keevik, Ms. Shelley Wolki, Ms. Bessie Hagan, and Ms. Sandra Hanson. The project was supported by American Diabetes Association Clinical Research award 1-08-CR-57, Government of Nunavut Department of Health and Social Services, Government of Northwest Territories Department of Health and Social Services, Health Canada, Public Health Agency of Canada, and the Nunavut and Northwest Territories Public Health Association.
Competing interests
The authors declare they have no competing interests.
Authors’ contributions
FK conducted the data analysis, drafted and finalized the manuscript. MP drafted the manuscript. EM and LB initiated and implemented the intervention in NWT and Nunavut and oversaw all field activities. AC critically reviewed the manuscript. SS developed the designed the study, trained data collectors, and oversaw data collection. All authors were responsible for interpretation of the data and critically reviewed its content and have approved the final version submitted for publication.