Saturday, 26 December 2015

Do discrimination, residential school attendance and cultural disruption add to individual-level diabetes risk among Aboriginal people in Canada?



Aboriginal peoples in Canada (First Nations, Metis and Inuit) are experiencing an epidemic of diabetes and its complications but little is known about the influence of factors attributed to colonization. The purpose of this study was to investigate the possible role of discrimination, residential school attendance and cultural disruption on diabetes occurrence among First Nations adults.


This 2012/13 cross sectional survey was conducted in two Saskatchewan First Nations communities comprising 580 households and 1570 adults. In addition to self-reported diabetes, interviewer-administered questionnaires collected information on possible diabetes determinants including widely recognized (e.g. age, sex, lifestyle, social determinants) and colonization-related factors. Clustering effect within households was adjusted using Generalized Estimating Equations.


Responses were obtained from 874 (55.7 %) men and women aged 18 and older living in 406 (70.0 %) households. Diabetes prevalence was 15.8 % among women and 9.7 % among men. In the final models, increasing age and adiposity were significant risk factors for diabetes (e.g. OR 8.72 [95 % CI 4.62; 16.46] for those 50+, and OR 8.97 [95 % CI 3.58; 22.52] for BMI 30+) as was spending most time on-reserve. Residential school attendance and cultural disruption were not predictive of diabetes at an individual level but those experiencing the most discrimination had a lower prevalence of diabetes compared to those who experienced little discrimination (2.4 % versus 13.6 %; OR 0.11 [95 % CI 0.02; 0.50]). Those experiencing the most discrimination were significantly more likely to be married and to have higher incomes.


Known diabetes risk factors were important determinants of diabetes among First Nations people, but residential school attendance and cultural disruption were not predictive of diabetes on an individual level. In contrast, those experiencing the highest levels of discrimination had a low prevalence of diabetes. Although the reasons underlying this latter finding are unclear, it appears to relate to increased engagement with society off-reserve which may lead to an improvement in the social determinants of health. While this may have physical health benefits for First Nations people due to improved socio-economic status and other undefined influences, our findings suggest that this comes at a high emotional price.
Keywords: Colonization, First Nations, Residential school, Racism, Discrimination, Diabetes mellitus, Social determinants of health


Aboriginal peoples in Canada (First Nations, Inuit and Metis) are experiencing an epidemic of type 2 diabetes (T2DM) [1, 2]. Compared to their non-Aboriginal counterparts, First Nations people not only have higher rates of diabetes [2] but are also more likely to develop diabetes if female [2], as younger adults [2], and during childhood and adolescence [3]. Thus, while average life span is shorter among diabetic First Nations people [4] compared to non-First Nations people, the years lived with diabetes is typically longer [4]. This prolonged exposure to the metabolic consequences of diabetes contributes to a greater risk for chronic complications such as diabetic kidney disease [5, 6], particularly when combined with reduced access to and quality of diabetes care [7, 8]. Understanding the mechanisms underlying these ethnicity-based differences is therefore important in developing effective primary and secondary prevention initiatives and in providing optimal management of diabetes and its complications.
While genetic factors contribute to the risk for T2DM [9], they cannot explain the rapid world-wide emergence of diabetes over the past few decades in diverse populations that include many Indigenous groups [10]. Instead, this pandemic has paralleled recent changes in environmental and possibly epigenetic factors [11] – these have been attributed to unprecedented disruptions in traditional lifestyles that have occurred in virtually all human populations, particularly since the middle of the past century [12]. Most attention has focused on the role of changing diets (e.g. higher consumption of simple carbohydrates and calorie dense foods) and reduced physical activity that have led to a parallel pandemic of overweight/obesity [13]. Indeed, overweight/obesity is an important diabetes risk factor among First Nations people which is compounded by a higher proportion with elevated body mass index (BMI) [14]. There is also mounting evidence that increasing rates of childhood obesity and T2DM are partly driven by an increased incidence of diabetic pregnancies among First Nations women – not only women with gestational diabetes [15] but also their children [16] have a higher risk for T2DM.
In addition to changes in lifestyle, it has become apparent that inequities in the social determinants of health (e.g. poverty, sub-standard housing, low educational attainment, poor food availability, unemployment) [17] are also important predictors of chronic diseases including diabetes [18], and are widespread in Aboriginal communities [19]. These factors are increasingly attributed to the impact of colonization that has severely undermined Indigenous culture and access to resources necessary to improve socio-economic status [20, 21]. In particular, discrimination has been identified as a potent social stressor that may increase vulnerability to physical illness through physiological, psychological and behavioral pathways [22]. The main purpose of this study was to determine if residential school attendance, indicators of cultural disruption and perceptions of discrimination were individual-level predictors of diabetes among adults in two First Nations communities in Canada after adjusting for other recognized diabetes risk factors.