Cardiovascular Disease and First Nations Communities



Cardiovascular Disease and First Nations CommunitiesRoberta PowerStenberg CollegeCardiovascular Disease and First Nations CommunitiesChronic disease has overtaken contagious disease as the number one health challenge for First Nations (FN) communities (Tjepkema, Wilkins, Goedhuis, & Pennock, 2012). Although FN communities within Canada are diverse and differ in levels of health and prosperity, they still suffer a disproportionate level of mortality and morbidity from chronic diseases compared with the non-Aboriginal population. Of these, cardiovascular diseases are the most lethal involving disorders of the heart and blood vessels of the body and include coronary artery disease, cerebrovascular disease, and peripheral artery disease (World Health Organization, 2013). Cardiovascular disease (CVD) is the leading cause of death among FN populations in Canada (Heart and Stroke Foundation, 2014). There are many known factors that increase the risk of developing CVD, both modifiable and non-modifiable. Among FN groups in Canada, modifiable risk factors for cardiovascular disease such as poor diet, physical inactivity, and tobacco use, are also disproportionally higher than in non-Aboriginal populations (Earle, 2011). Consequently, FN populations suffer from a disproportionate amount of CVD due to these increased risk factors. Chronic diseases, such as CVD, are those that develop over a long period of time and are influenced by both environmental and individual factors (Earle, 2011). The steady increase in prevalence of CVD over the past 50 years is likely due to the significant transitions in lifestyle and traditional ways of living FN communities have experienced (Retnakaran, Hanley, Connelly, Harris, & Zinman, 2005). The effects of colonization, disconnection from the land, forced assimilation, and loss of traditional practices in favor of Westernized lifestyles, have led to this heavy CVD burden in FN populations.An important factor in FN high incidences of CVD is the loss of cultural connection with the land and traditional ways of living and eating. Aboriginal people in Canada have undergone significant nutritional transitions whereby traditional diets and associated physical activities have been replaced with patterns of consumption that increase the risk of developing CVD (Earle, 2011). As FN people have lost access to traditional lands for the purposes of hunting and gathering, and legislative restrictions on the use of land and animal resources has impacted their ability to sustain themselves as they had precolonization, traditional foods have become limited or obsolete in many communities (Earle, 2011). Instead, a dependence on processed and Westernized foods typically high in fat and sugar has evolved. As well, limited food choices and food insecurity in remote communities, coupled with a sedentary lifestyle, has led to a 2.5 fold higher incidence of CVD compared to non-FN people (Hemmelgarn, 2014). Another study, which took into account gender, income levels, and educational attainment between FN and non-FN cohorts, still concluded that mortality rates for FN men and women from CVD was 30% and 76% respectively (Tjepkema et al., 2012). Higher education and adequate income minimized the impact of CVD for FN people able to attain this, but did not eliminate the health disparities between FN and non-FN populations (Tjepkema et al., 2012). This indicates that socioeconomic factors alone do not explain the health inequities (Tjepkema et al., 2012).Historically, FN diets consisting of traditional foods were those that originated from local plant or animal resources through hunting and gathering (Earle, 2011). Although foods and nutrient intake varied by local geography and season, in general FN diets were high in animal protein, nutrient rich, and low in fat (Earle, 2011). As well, the energy required to obtain these foods was quite significant given the physical demands of hunting, fishing, trapping, growing, and gathering. Without the need for physical activity, obesity has become a major concern as well in FN populations with a prevalence of 38% compared with 23% of the general population (HSF, 2014). Further, more than 40% of FN youth are either overweight or obese (HSF, 2014). It should be noted that the incidence of obesity varies widely across the country and between groups. Obesity is also a known risk factor for CVD and higher incidence of CVD are reported in those who are overweight or obese (HSF, 2014). Data on FN adults living off-reserve reveal 58.3% are physically inactive contributing to significant weight gains (Earle, 2011).Traditional aboriginal foods tend to be lower in carbohydrates, including simple sugars, and contain healthier profiles of fats such as Omega-3 fatty acids found in fish and fish oil found to decrease the risk of CVD (Earle, 2011). Reclaiming the benefits of healthier traditional diets and active living has been the focus of many preventative interventions among FN communities in recent years. For example, an initiative funded by the Heart and Stroke Foundation and the Provincial Health Services Authority of BC saw the development of 15 community gardens in remote BC FN communities. The Food Systems in Remote First Nations project is a two-year initiative designed to support the communities to integrate gardening into their meal planning and provide a means of having fresh vegetables available year-round, as well as incorporating physical activity back into their lifestyle (Ministry of Health website, 2012).Tobacco use is another significant risk factor in developing CVD. FN populations have a 60% prevalence rate of smoking compared to 25% among other Canadians (Earle, 2011). Inuit communities in the North have the highest rates of smoking at 70% with almost half of these smokers beginning before age 14 (Earle, 2011). Cigarette smoking is a primary cause of preventable death in Western society and is associated with CVD (HSF, 2014). Most alarming, is the remarkably high rates of smoking among youths aged 10-19 years in FN communities at rates of 33%, or one in three, compared with 8% in non-FN youth (National Collaborating Centre for Aboriginal Health website, 2013). A study by the Canadian Medical Association, which examined smoking as a risk factor among FN youth and early signs of CVD, provided evidence linking childhood daily smoking exposure with future atherosclerotic disease and high blood pressure as adults (Retnakaran et al., 2005). As the single most modifiable risk factor for development of CVD, it is clearly important that strategies for smoking cessation be aimed toward this age group in light of the growing prevalence of CVD related deaths in this population. Some communities are taking action to help their members quit smoking, particularly focusing on their youth. For example, the Sandy Lake community in Ontario has a community-based youth smoking intervention program aimed at addressing lifestyle factors associated with chronic disease such as CVD and diabetes (Earle, 2011). As well, community leaders and Elders are attempting to educate their youth on the traditional and sacred use of tobacco as opposed to the non-traditional and harmful uses of commercial tobacco products (NCCAH, 2013).Tobacco has been used by FN for centuries in ceremonies, rituals, and prayer. This is considered traditional and sacred use of tobacco products when used in this way, benefiting the spirit and strengthens the ties to one’s culture (NCCAH, 2013). However, the use of non-traditional tobacco such as smoking is considered abuse of its original purpose (NCCAH, 2013). High rates of smoking may be due to lack of education about health effects, early addiction, and the perceived benefits of nicotine such as relieving boredom, anxiety, or irritability (NCCAH, 2013). Lifestyle transitions and cultural disconnection due to colonization and assimilation efforts have left many communities living a stressful existence of marginalization and idleness (Waldram, Herring, & Young, 2007). Smoking may be one way of coping with these conditions in communities where survival supersedes choices for good health and consequently, chronic disease burdens such as diabetes and CVD are the result of this lack of choices. Although diabetes is a separate and equally prevalent chronic disease in FN populations, the impact on individuals with concomitant CVD should be discussed. It is not unusual for chronic disease sufferers to have more than one illness. Heart disease and hypertension are about four times more prevalent among FN adults with diabetes as among those without (HSF, 2014). As well, Type II diabetes is being diagnosed with increasing rates among FN children and youth (HSF, 2014). Prevalence varies by community across the country, but the overall trend has been increasing at an alarming rate, occurring earlier in life, and tending to have more severe side effects than in the general population (Earle, 2011). This is significant because diabetes is a known risk factor for CVD and accelerates the development of CVD due to vessel damage at the microvascular level, thus diabetes increases the risk of amputation in these individuals (Wipke-Tevis & Rich, 2014, Chapter 40). For example, in people with diabetes mellitus, peripheral artery disease (PAD) occurs much earlier which leads to a higher CVD mortality (Wipke-Tevis & Rich, 2014, Chapter 40). Further, PAD is a marker of advanced systemic atherosclerosis; patients who have diabetes and atherosclerotic vascular disease are at the highest risk for cardiovascular events such as heart attacks, strokes, and CVD-related death (Wipke-Tevis & Rich, 2014, Chapter 40). The Canadian Diabetes Association (2008 Clinical Practice Guidelines) stress the importance of lifestyle modifications such as achieving a healthy body weight, regular physical activity, smoking cessation, and optimal blood pressure and blood glucose control to reduce CVD risk factors (Wipke-Tevis & Rich, 2014, Chapter 40). Diabetes and CVD share many of the same risk factors such as poor diet, physical inactivity, obesity, and the use of tobacco. Health initiatives focused on FN populations are proving to be most successful when traditional and holistic approaches are incorporated into health services and programs (Earle, 2011). Incorporating these approaches will also influence access and utilization of health services by increasing their cultural relevance and value (Earle, 2011). For example, some of the best-attended components of a diabetic intervention program among the Haida were traditional diet and herbal medicine trials (Earle, 2011). FN groups disproportionately suffer from chronic disease and their risk factors compared with the general population in Canada (Earle, 2011). Chronic disease such as CVD among FN communities will only be effectively treated when health initiatives come from within those communities themselves and traditional ways of living and eating can be re-established. Such initiatives may directly influence modifiable risk factors such as diet, physical activity, and especially smoking cessation. Traditional diets and the associated physical activities of FN people have been profoundly altered by the efforts of colonization and forced assimilation particularly over the past half century (Waldram et al., 2007). Traditional lifestyles have been replaced with a Westernized diet and lifestyle which typically includes a high fat and sugar content as well as physical inactivity. Traditional foods have been shown to contain beneficial fat, carbohydrate, and nutrient profiles as well as being an important cultural connection (Earle, 2011). It is also clear that FN children and youth should be targeted for specific health education and lifestyle modifications due to the early risk factors for CVD and other chronic diseases this group is exhibiting (Retnakaran et al., 2005). Despite challenges such as remote geography, food insecurity, lower educational achievements, and poverty, traditional diets and lifestyle appear to be important for chronic disease prevention and their revival within FN communities can be successfully implemented when presented in culturally relevant ways (Earle, 2011). Further, incorporation of FN traditions and culture into programs designed to improve health outcomes contributes to the recovery of indigenous knowledge that is an important part of the decolonization process (Earle, 2011). ReferencesEarle, L. (2011). Traditional Aboriginal diets and health. Retrieved from National Collaborating Centre for Aboriginal Health: , L. (2011). Understanding chronic disease and the role for traditional approaches in Aboriginal communities. Retrieved from National Collaborating Centre for Aboriginal Health: and Stroke Foundation website. (2014). , B. R. (2014, May 20). Likelihood of coronary angiography among First Nations patients with acute myocardial infarction. Canadian Medical Association Journal, 1-8. of Health website. (2012). , M. (2012, January 26). First Nations need obesity prevention. Socio-economic issues contribute to hypertension, heart disease and diabetes epidemic, report says. The Montreal Gazette. Retrieved from Collaborating Centre for Aboriginal Health website. (2013). , R., Hanley, A., Connelly, P., Harris, S., & Zinman, B. (2005, October 11). Cigarette smoking and cardiovascular risk factors among Aboriginal Canadian youths. Canadian Medical Association Journal, 173(8), 885-889. , M., Wilkins, R., Goedhuis, N., & Pennock, J. (2012). Cardiovascular disease mortality among First Nations people in Canada, 1991-2001. Chronic Diseases and Injuries in Canada. Public Health Agency of Canada, Ottawa, Canada.Waldram, J. B., Herring, D. A., & Young, T. K. (2007). Aboriginal health in Canada: Historical, cultural, and epidemiological perspectives (2nd ed.). Toronto, Canada: University of Toronto Press.Wipke-Tevis, D., & Rich, K. (2014). Medical-surgical nursing in Canada: Assessment and management of clincial problems (3rd ed.). M. Barry, S. Goldsworthy, & D. Goodridge (Eds.). Toronto, Canada: Elsevier Canada.World Health Organization Cardiovascular diseases (CVDs). (2013). Retrieved from ................
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