Mapping of Dietary Risks in Indigenous People: A Scoping Review

Around 370 million indigenous people worldwide are the most marginalized people; members of the group die relatively younger than their non-indigenous compatriots [1-4]. During 2009-2013, 81% of indigenous Australians died before the age of 75 years, compared with 34% of the non-indigenous Australian [5]. Indigenous peoples’ early deaths in most of the nations across the globe result in significant life expectancy gaps (LEG) compared to the rest of the population, including some of the wealthiest countries of the world [6-9]. There was a time when Indigenous people lived in their healthiest state [10]. Many studies relate wellbeing to their traditional way of living – largely described by consumption of traditional food and intense physical activity due to leading hunter-gatherer life style [11-13]. Traditional foods had special value among indigenous communities. It was a way to keep their relationships with their environment, cultures and traditions. The concept of being able to consume traditional food was related to their overall health [14]. However, the modern lifestyle does not support their old way of living any more. The change from a traditional food based diet energy dense processed food witnessed introduction of alien diseases such as diabetes, hypertension, cardiovascular disease and cancers in varied populations across the globe [15-17]. Therefore, in the present review, we focus to study literature surrounding indigenous health and their dietary habits in modern age to suggest future solutions to indigenous health.

We conducted scoping review based on the available literature to assess breadth of the topic, identify any gaps and summarise our findings [18]. The idea was to provide an overview of the work performed in this area, and its extent [19]. The stages for conducting scoping review was as follows:
I. Identification of the research question
II. Identification of relevant studies
III. Study selection
IV. Charting the data
V. Summarizing and reporting of data

Online databases - PubMed, Web of Science, Scopus and Social Science ProQuest were searched for indigenous people’s dietary intake information (Table 1). National repositories and reports were searched by accessing country national websites. Manual searching was also conducted on Google Scholar to avoid missing of important relevant articles. The search strategy for electronic databases was developed with the requisite skill in devising appropriate search strategies. The first author holds experience in searching databases and is equipped with literature search experience. Two search strategies were developed in order to fetch the relevant articles for conducting scoping review of the concept. 1. Nutritional health issues related articles. 2. Dietary intake related articles. Keyword used along with Boolean operators-indigenous, tribal, diet, dietary intake, food, food intake, health problem, health issue, health, disease, aboriginal, aboriginal and torres strait islander, disease, diabetes, overweight, obesity, hypertension, undernutrition, malnutrition, traditional food, over nutrition, energy intake, nutritional disorder. Inclusion and Exclusion criteria: Those articles/documents which mentioned about the food intake and nutritional disorders in indigenous people were retained. The literature were selected for last 10 years and anything prior to that was excluded. Any article other than diet and existing health condition information was excluded from further analysis. Any non-English documents and duplicates were also excluded during refining process. Most importantly, the articles that showed a comparison between indigenous and non-indigenous populations in the same region were retained.

Table 1:

Amongst, all the combinations, INDIGENOUS AND “DIETARY INTAKE” keyword combination yielded the best relevant results for information pertaining to diet in indigenous population. Hence, the number of results were used to analyze the number of articles from source countries. In article title Scopus-7documents were retrieved but after applying a filter for last 10 years 5 articles appeared in the search results. After removal of duplicates and non-English literature, 2 articles were retained for analysis and they were both from Australia. The articles discusses about disparities in dietary intake and anthropometric measurements. In Abstract when searched, 84 documents appeared however for the last 10 years 47 articles were extracted for analysis. Out of 47 records in Abstract filter, one article from Norway reported no ethnic differences in the dietary intakes of indigenous and non-indigenous populations. The article when searched in PubMed had 53 records for the last 10 years. Out of these articles, 52 had these keywords in the abstract section. Two articles were from India-1. Oraon tribal women, Jharkhand, and 2. Santhal community Jharkhand. Both estimated indigenous food consumption to dietary consumption in tribal women. Two articles were retained from Canada 1. Study among Cree people in norther Quebec, and 2. First nations in 4 Canadian provinces. Two articles, both from Australia, were duplicated as of Scopus results. Similar Norway study of no ethnic disparity in dietary intake was obtained during PubMed search. In Web of Science search, 40 articles belonged to the field of “Nutritional Dietetics”, 25 in “Public Environmental and Occupational Health”, 8 in “Environmental Sciences”, 5 in “Food Science and Technology” and 4 in “Anthropology”. When searched in “Nutritional dietetics”, 11 articles were already been retrieved during Scopus and PubMed searches. 7 new articles were included from Web of Science search. Social Science ProQuest database search yielded Cultural Anthropology (34), Physical Anthropology (29), Public health (26), Nutrition (25), Studies (22), Food (18), Diet (16), Food Supply (14), and Humans (11) related articles. One article was replicated in the search result. 4 new articles were included from social science database ProQuest search results. Maximum number of articles from above databases were from Canada (78), Australia (69), United States (62), New Zealand (14) and India (18). 241 articles came from these 5 countries out of 433 total articles retrieved. The diseases related to nutritional disorders were mapped in the above mentioned countries. Search keywords included- diabetes, obesity, hypertension, high blood pressure, malnutrition, and excess nutrition. 40 articles were included which discussed the prevalence of nutrition related health problems in indigenous populations [20-87] (Table 2).

Table 2:

Only one study was found which contained both dietary intake and anthropometric measurements from Australia [22]. Another, study in northern Australia reported overweight/obese Ind youth were 1.89 times more likely to eat dugong (a traditional food –sea mammal) [88]. Increase in market food consumption and BMI was reported in a study from Canadian indigenous people [89]. In the northern Quebec Cree population, where obesity rates were significantly high, individuals drank high sugar containing beverage everyday contributing 5.28%±8.98% to total energy intake [36]. Ultra-processed food was highly related with metabolic syndrome in Cree of northern Québec, Canada [90]. In three Cree communities of northern Quebec, reported as 67.6% overweight prevalent region, 96.8% people consumed 39% of total energy from high fat foods, and 92.8% consumed 12.8% of total energy from high sugar foods [91]. In three communities of Nunavat Canada, where obesity prevalence was ˃ 70%, non-nutrient dense foods were primary source of fat, carbohydrates and sugar [42]. In New Zealand, Obese Ind child’s medium sweet beverage consumption is reported in comparison with nonindigenous child [31]. Overweight vs normal weight children reported significantly more sweetened beverage intake (8.0±0.10 vs 5.28±0.08 oz/day, P<0.01) [53]. In India, maternal malnutrition post-natal high salt intake is thought to be associated with hypertension [92]. This is based on the hypothesis that similar results have been observed in animals, wherein animal the deficiency of macro and micronutrients led to nephron endowment which made them susceptible to high salt sensitive and both of these factors together predispose to hypertension. This basis has been applied to suggest similar effects on population affected by malnutrition endemic. Especially countries like India where poor rural and vulnerable population face significant burden of malnutrition. In Mandla district of India, in 3090 adult tribals, hypertension was strongly associated with increase in BMI especially those BMI who had greater than 25. The prevalence of hypertension was significantly greater among those whose salt intake was more than 10 g per day [93]..

when TF was consumed, there was a higher intake of protein, iron, vitamins A, C, D minerals such as magnesium and a lower intake of carbohydrates, saturated fat, and fiber and a lower sodium: potassium ratio (P≤0.05) [36,94]. Traditional food contributed 56% of protein and 49% of iron in three communities of Nunavat, Canada [40] and 40% and 42% respectively in other two commu nities for protein and iron respectively [46]. In santhal Community women in Jharkhand, India – those women who consumed indigenous food in past two days of survey had higher intake levels of calcium and iron levels [65]. In three communities of Nunavat, Canada, traditional food for 21% energy and ˃ 50% intakes of protein and iron [42]. Consumption of native marine foods has decreased significantly in Alaskan native women since 1960 and is highly associated with serum vitamin levels [95]. Among Inuits, lead exposure was associated as a potential cause of Unexplained Anaemia, where the participants were not iron deficit. The unexplained anaemia was highest in traditional regions [96]. Lead intake - 1.7 times higher in Ind vs non-Ind [97] and Methylmercury - 1.6 times higher in Ind vs non-Ind [98].

Low education and income people groups including American Indians/Alaskan Natives are vulnerable to added sugar [99]. In Thangkhul in Manipur, North east, overweight (25.1%) in tribal women was associated with higher socioeconomic status especially occupation and income – when compared to their non-tribal counterparts [100]. A study in Peninsular Malaysia, food insecure group is significantly associated with higher BMI with multivariate analysis of covariance and also in a group where child hunger was most prevalent high fat and sodium intake scores were reported than food secure groups [86]. In contrast, Income and wealth were significantly associated with fatness measures. They also reported income and adiposity increase during 1962-2006 in Xavante people in Brazilion Amazon [101].

There have been 16 studies reporting differences in nutrition related health problems of indigenous people compared to non-indigenous people in respect of type 2 diabetes, obesity, blood pressure, stunting, malnutrition, double burden of malnutrition, anaemia. 3 studies discussed nutritional discrepancies in terms of excess consumption of an unhealthy diet pattern- sweet beverage consumption (2) and total energy intake (1). Saturated fat and sodium leading contributors in the etiologies of nutrition related health issues [102-104] were not compared in the two populations. 2 articles compared indigenous person’s micronutrient deficiency in comparison with non-indigenous individual. Other studies report these deficiencies in comparison with recommended nutritional values. Total 18 studies reported unhealthy excess intake of at least one of the items - saturated fat, sugary food, salt or sodium, and non-nutrient dense/store bought/highly processed food. 8 studies – 6 from Canada, 1 from Australia and 1 from America discussed about consumption of store bought or highly processed or non-nutrient dense food. 6 studies discussed high sweet beverage consumption or added sugar exceeding the recommended limit or sugar contribution from high processed foods. 5 articles discussed about high fat consumption. 5 articles discussed excess salt or sodium intake out of which three were from India, Nepal and Malaysia. We did not find excess intake of any other macronutrient in studies from India and Nepal. One study from peninsular Malaysia reported excess intake of both fat and salt in child hunger group and higher BMI’s association in food insecure group. Total 25 articles reported vitamin and mineral deficiencies in these countries, with some concurrent deficiency articles in India. Deficiencies are common in all the countries included in the present study - Australia (2), New Zealand (2), Canada (9), America (5), India (6), Nepal (1), and Peninsular Malaysia (1). Canada and India has maximum number of articles published. The vitamins found deficient in these population were Vitamin A, C, D, E, K, B6, B12, folate, riboflavin. Minerals such as iron, calcium, magnesium, potassium, zinc. Less than adequate consumption of fruits, vegetables & fibre is reported in 3 articles. Protein is the only macronutrient whose deficiency is reported in an article from Indian subcontinent. Two studies reported deficiencies in comparison with their non-indigenous counterparts. Three studies report vitamin A & D deficiency and inadequate fruit and vegetable consumption in indigenous child, two from Canada and one from India. 1 study assessed dietary intake and anthropometric measurement directly. 9 studies find indirect association of exploring high intake consumption patterns in obesity prevalent regions. Two studies in India aim to relate hypertension with salt intake by an indirect association. 7 articles discussed the potential benefits of traditional food consumption in communities today. It increased intake of vitamins and minerals including protein and decreased intake of carbohydrate, fat and sodium. One study from Canada reports less intake while on ultra- processed food compared to being on non-processed diet in terms of Vitamin A, K and protein intake. 3 studies discussed low income, education and food insecure group as vulnerable for high fat, sugar and sodium intake and therefore increase in BMI. In India, 1 study related increased overweight in tribal women with an increase in income.

The attempt to study dietary patterns across indigenous populations and identify any trend is the major strength of this review. Indigenous culture is diverse and unique however, the health gap is common in most of the countries of their presence. Hence, with the help of present study, we intended to collect as much information available to look for patterns that could help stakeholders take informed decisions. Use of online databases, systematic search of relevant articles, manual searching to identify any missing article during database search, refining and extraction of appropriate data and working of two authors individually to screen relevant articles were crucial aspects during the study. The limitation exist, in the exclusion of articles in indigenous languages that could have added to the trends discovered in the present study. Additionally, indigenous people are widely spread and lack of data pertaining to diet from all those countries and indigenous communities within the same country is a major limitation.

Nutrition related health disorders are prevalent in indigenous people and their contribution to causing health gap is obvious in light of the comparisons presented with respect to non-indigenous people in the same region. Non-nutritive dense food appears to be a major contributor to the imbalanced health factors. However, the strong evidential support comparing dietary and metabolic risk factor in the indigenous and non-indigenous population remain scarce. Sugar, saturated fat and sodium are major contributors of imbalanced energy intake in indigenous people, the primary source being store bought non nutrient dense foods in Australia, New Zealand, Canada and America. Excess intakes are hardly reported in studies from India and Nepal except salt but they are nowhere less in terms of reporting deficiencies. Based on available articles, we can say that micronutrient deficiencies are profound in indigenous people across regions whereas excess consumption is significant in affluent nations. Since low income, education and food unsecure groups might show vulnerability towards developing unhealthy consumption behavior, the increase in the socioeconomic status of indigenous people in developing economies should be targeted for creating healthy food environment models where excess consumption can be avoided and deficiencies could be balanced with nutrient dense diet system. More studies are needed to validate the excess consumption behavior and micronutrient deficiencies guided by highly processed foods in indigenous population. However, the research base is sound to support traditional food’s association with increased intakes of vitamins and minerals. In a population, where traditional foods have diminished and there in inadequate fruits and vegetable intake as the source of rich vitamins and minerals, appropriate strategies are needed to develop a system for providing balanced nutrients.

Authors thank Drs Prashant Srivastava, Dane Lamb, Ayanka Wijayawardena and Morrow Dong for their support during research.

The authors have no conflicts of Interest to declare.

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