Abstract
OBJECTIVES:
To determine cardiovascular risk factors and health behaviours in Aboriginal children from the Beaufort-Delta region (Northwest Territories).
METHODS:
A total of 91 elementary school-age children underwent a cross-sectional assessment of body mass index, waist circumference, blood pressure and aerobic fitness. Healthy living knowledge and behaviours, including frequency of self-reported physical activity (PA) and dietary intake, were also evaluated.
RESULTS:
A total of 49.5% of children were obese/overweight and 31.9% had elevated blood pressure. The percentages having one, two or three cardiovascular risk factor(s) were 64.4%, 42.2% and 15.6%, respectively, with no significant difference between boys and girls. Overall, the students obtained higher mean scores in the areas of healthy PA, body image, self-esteem and nutritious beverage knowledge (89%, 85%, 79% and 71% of the maximum scores, respectively). The lowest scores were in nutritious food consumption and healthy PA frequency (46% and 56% of the maximum scores, respectively). On average, children consumed 2.7 L of sugar-sweetened beverages weekly and <2 servings of fruits or vegetables daily. Children spent approximately 2 h per day watching television, playing games or using a computer.
CONCLUSION:
There is an urgent need for community-based approaches to address the high rates of obesity and related cardiovascular risk factors among these Aboriginal children. Given the disconnect between healthy living knowledge and behaviour, it is important that future treatment programs address other barriers faced by Aboriginal populations living in rural and remote regions, including the high cost and limited access to high-quality nutritious foods and beverages, and limited access to indoor recreational programs over the long winter season.
Keywords: Aboriginal, Cardiovascular risk, Diabetes, Obesity, Overweight, Prevention
Abstract
OBJECTIFS :
Déterminer les facteurs de risque cardiovasculaire et les comportements de santé des enfants autochtones de la région de Beaufort-Delta (Territoires du Nord-Ouest).
MÉTHODOLOGIE :
Les chercheurs ont effectué l’évaluation transversale de l’indice de masse corporelle, du tour de taille, de la tension artérielle et de la capacité aérobique de 91 enfants du primaire. Ils ont également évalué leurs connaissances et leurs comportements liés à un mode de vie sain, y compris la fréquence de l’activité physique (AP) et la consommation alimentaire autodéclarées.
RÉSULTATS :
Au total, 49,5 % des enfants étaient obèses ou faisaient de l’embonpoint, et 31,9 % avaient une tension artérielle élevée. De plus, 64,4 %, 42,2 % et 15,6 % d’entre eux avaient un, deux ou trois facteurs de risque cardiovasculaire, respectivement. Il n’y avait pas de différence significative entre les garçons et les filles. Dans l’ensemble, les élèves obtenaient des résultats moyens plus élevés en matière d’AP saine, d’image corporelle, d’estime de soi et de connaissances sur les boissons nutritives (89 %, 85 %, 79 % et 71 % des résultats maximaux, respectivement). Les résultats les plus faibles étaient liés à la consommation d’aliments nutritifs et à la fréquence d’AP (46 % et 56 % des résultats maximaux, respectivement). En moyenne, les enfants consommaient 2,7 litres de boissons sucrées par semaine et moins de deux portions de fruits ou de légumes par jour. Les enfants consacraient environ deux heures par jour à regarder la télévision, à jouer à des jeux ou à utiliser l’ordinateur.
CONCLUSION :
Il est urgent d’adopter des approches communautaires pour atténuer les taux élevés d’obésité et de facteurs de risque cardiovasculaire connexes chez ces enfants autochtones. Étant donné la dichotomie entre les connaissances sur un mode de vie sain et le comportement, les prochains programmes thérapeutiques devront absolument tenir compte des autres obstacles qu’affrontent les populations autochtones des régions rurales et éloignées, y compris l’accès limité à des aliments nutritifs et des boissons de qualité et leur coût élevé, de même que l’accès limité aux activités récréatives intérieures pendant la saison hivernale.
Aboriginal adults in Canada are three to five times more likely to develop type 2 diabetes mellitus (T2D) compared with the general Canadian population (1); the highest rates of T2D occur in individuals living in remote environments (2). It is not surprising that T2D rates have increased in Aboriginal children as Aboriginal people have adopted a Westernized lifestyle (3). Effective prevention is essential given that the onset of T2D during childhood is associated with severe and early onset of micro-vascular complications including retinopathy, neuropathy and nephropathy (4,5).
Obesity is a major but modifiable risk factor for T2D. The prevalence of overweight and obesity in Canadian Aboriginal children and youth living on reserves has been documented to be 56% and 43%, respectively (2); in contrast, 26.3% of Canadian non-Aboriginal children and youth are overweight or obese (6). Obesity tracks from childhood into adulthood (7); adults who were obese during childhood have a two to three times increased rate of developing chronic diseases, such as diabetes, hypertension and cardiovascular disease, compared with the general population risk (8).
In the Northwest Territories, there has been a 31% increase in diabetes in individuals >12 years of age from 2001 to 2005 (9). This observation, along with recent study findings that 78% of Inuvialuit children three to five years of age are overweight or obese (10), have prompted key stakeholders in the Beaufort-Delta region of the Northwest Territories to develop a strategy to reverse this trend.
As a first step in the planning of a school-based intervention for this region, we worked collaboratively to conduct a baseline evaluation at one elementary school in the Beaufort-Delta region. The purpose of the present study was to evaluate the prevalence of cardiovascular risk factors, including obesity/overweight status, along with healthy living knowledge and behaviours in school-age Inuvialuit and Gwich’in children from a single elementary school.
METHODS
Study design and population
The present study was a cross-sectional assessment of children attending grades 2 to 6 within one elementary school in the Beaufort Delta Health and Social Services Authority conducted in November 2010. The Beaufort-Delta region includes eight remote communities, situated north of the Arctic Circle in the Northwest Territories, and is home to approximately 7000 Gwich’in and Inuvialuit residents. The study was approved by the University of British Columbia (Vancouver, British Columbia) Research Ethics Board, the Beaufort Delta Health and Social Services Authority, the Inuvialuit Regional Corporation, the Gwich’in Tribal Council and the Beaufort-Delta Education Council. Parents/guardians provided written informed consent and children provided written assent to participate. All study-related documents (including the consent and assent forms and study questionnaires) were provided in English, which is the language of instruction at the school. A translator was available through both the school and the community health centre if needed.
Data collection
Anthropometric measurements:
Measurements were obtained at the school during regular school hours by trained research assistants. Children were asked to wear light clothes without shoes and socks. Weight, height and waist circumference (WC) were recorded as an average of two readings. Weight was measured in kg (to the nearest 0.1 kg, digital electronic scale, Conair Corporation, USA), and height was measured to the nearest 0.1 cm (Seca 214 Portable Stadiometer). Body mass index (BMI) was calculated (weight [kg]/height squared [m2]) and converted to a z-score (11). Weight status was categorized as obese (BMI ≥95th percentile), overweight (BMI ≥85th and <95th percentile) or normal (BMI <85th percentile) (12). WC was measured using a nonelastic flexible tape measure at the level of the umbilicus at the end of the expiration and recorded to the nearest 0.1 cm (13). WC was categorized as ≥90th or <90th percentile for sex and age (14). Blood pressure and heart rate (recorded as an average of three readings) were measured on the left arm and recorded in mmHg and beats/min, respectively (Dinamap Pro 300, Critikon, USA). Hypertension was defined as having either a systolic blood pressure or diastolic blood pressure ≥95th percentile for age, sex and height (15). Prehypertension was defined as having systolic or diastolic blood pressure ≥90th and <95th percentile (15).
Behavioural questionnaires:
Healthy living knowledge and behaviours were assessed in all participants using the validated Healthy Buddies Questionnaire (HBQ) (16–18). The HBQ consists of nine scales to assess: nutritious food knowledge; nutritious beverage knowledge; healthy physical activity knowledge; healthy physical activity frequency; sedentary activity frequency; nutritious food consumption; nutritious beverage consumption; healthy living knowledge and self-esteem; and healthy body image.
The Food Frequency Questionnaire, adapted from the United States National Cancer Institute’s National Institutes of Health: Eating at America’s Table Study Quick Food Scan (19), was used to assess sugar-sweetened beverage, milk, vegetable and fruit consumption. A modified version of the Physical Activity Questionnaire for Older Children (PAQ-C) was used to calculate a physical activity score (PAQ score), ranging from 1 (low active) to 5 (very active), and to determine daily screen time (20).
Children completed all questionnaires with the assistance of the research team and their classroom teacher. Only students in grades 4 to 6 completed the Food Frequency Questionnaire and PAQ-C due to their complexity.
Aerobic fitness:
Physical fitness was assessed in grade 4 to 6 students using the validated multistage 20 m shuttle run test (21). The test was administered in the school gymnasium in small groups while the students received verbal encouragement from their peers. The total number of completed laps was recorded (22), and maximal oxygen uptake (VO2 max) was predicted using a regression equation (21). Low aerobic capacity was defined as having a VO2 max below the age- and sex-specific standards for the healthy fitness zone (23).
Cardiovascular risk assessment:
Each grade 4 to 6 student underwent a cardiovascular risk assessment for the presence of the following risk factors: obesity/overweight; WC ≥90th percentile (14); prehypertension or hypertension; and low aerobic capacity.
Data analysis
Data are reported as mean ± SD for continuous variables, and as frequencies and percentages for categorical variables. Differences of values between boys and girls were compared using χ2 and Fisher’s exact tests for categorical variables, and Kruskal-Wallis test for continuous variables. All statistical analysis was performed using Stata version 12.1 (StataCorp, USA); P<0.05 was considered to be statistically significant.
RESULTS
Demographic and anthropometric characteristics
Of the 115 eligible students, 91 (79%) consented to participate and 89 completed all study procedures, with partial data available for the remaining two students. The demographic and anthropo-metric characteristics of the participants are presented in Table 1. The mean (± SD) age of all participants was 9.2±1.8 years (range seven to 12 years). A total of 49.5% of all students were over-weight or obese, 35.2% had a WC ≥90th percentile, and 31.9% had hypertension or prehypertension. There were no significant differences in demographic and anthropometric parameters between male and female students (Table 1).
TABLE 1.
Demographic and anthropometric characteristics of all participants
| Characteristic | All (n=91) | Girls (n=53) | Boys (n=38) | P* |
|---|---|---|---|---|
| Demographic characteristics | ||||
| Age, years, mean ± SD | 9.2±1.8 | 9.3±1.8 | 9.2±1.9 | 0.632 |
| Grade | ||||
| 2 | 39 (42.86) | 23 (43.40) | 16 (42.11) | 0.319 |
| 3 | 5 (5.49) | 1 (1.89) | 4 (10.53) | |
| 4 | 6 (6.59) | 5 (9.43) | 1 (2.63) | |
| 5 | 7 (7.69) | 5 (9.43) | 2 (5.26) | |
| 6 | 34 (37.36) | 19 (35.85) | 15 (39.47) | |
| Anthropometric characteristics | ||||
| Body mass index, kg/m2, mean (±SD) | 20.0±4.5 | 20.3±4.9 | 19.5±3.8 | 0.676 |
| Body mass index, z-score, mean (±SD) | 0.90±1.06 | 0.92±1.03 | 0.87±1.11 | 0.891 |
| Weight status | ||||
| Overweight | 20 (22.0) | 12 (22.6) | 8 (21.1) | 0.960 |
| Obese | 25 (27.5) | 14 (26.4) | 11 (29.0) | |
| WC, cm, mean (±SD) | 70.1±12.4 | 70.3±12.6 | 69.8±12.1 | 0.828 |
| WC ≥90th percentile for age and sex | 32 (35.2) | 19 (35.9) | 13 (34.2) | 0.872 |
| Heart rate, beats/min, mean ±SD | 87±12 | 86±11 | 87±13 | 0.907 |
| Systolic blood pressure z-score, mean ±SD | 0.46±0.97 | 0.41±1.01 | 0.53±0.92 | 0.652 |
| Diastolic blood pressure z-score, mean ±SD | 0.66±0.94 | 0.78±1.11 | 0.48±0.62 | 0.292 |
| Prehypertension | 12 (13.2) | 7 (13.2) | 5 (13.2) | 0.506 |
| Hypertension | 17 (18.7) | 12 (22.6) | 5 (13.2) |
Data presented as n (%) unless otherwise indicated. Small differences in percentage may be due to rounding.
Difference between boys and girls. WC Waist circumference
HBQ
The results of the HBQ are presented in Table 2. Girls obtained significantly higher scores than boys in nutritious food knowledge (P=0.012). Overall, the students obtained higher mean scores in the areas of healthy PA knowledge, healthy body image, healthy living knowledge/self-esteem and nutritious beverage knowledge (89%, 85%, 79% and 71% of maximum score, respectively). The lowest scores were in nutritious food consumption and healthy PA frequency (46% and 56% of maximum score, respectively) (Table 2).
TABLE 2.
Healthy Buddies Questionnaire results
| Characteristic | Maximum score | All (n=91) | Girls (n=53) | Boys (n=38) | P* |
|---|---|---|---|---|---|
| Nutritious food knowledge | 42 | 26.5±6.2 | 27.8±6.3 | 24.6±5.6 | 0.012 |
| Nutritious beverage knowledge | 14 | 10.0±2.3 | 9.9±2.3 | 10.2±2.4 | 0.607 |
| Healthy physical activity knowledge | 20 | 17.7±2.3 | 17.5±2.5 | 18.0±1.9 | 0.364 |
| Healthy physical activity frequency | 32 | 17.9±4.9 | 18.5±4.4 | 17.2±5.4 | 0.209 |
| Sedentary activity frequency | 12 | 8.1±2.1 | 7.9±2.1 | 8.4±2.1 | 0.225 |
| Nutritious food consumption | 42 | 19.3±5.1 | 20.0±4.8 | 18.3±5.4 | 0.143 |
| Nutritious beverage consumption | 14 | 8.9±2.3 | 9.2±2.2 | 8.6±2.4 | 0.259 |
| Healthy living/self-esteem | 68 | 53.8±9.0 | 56.8±6.6 | 49.2±10.4 | 0.050 |
| Healthy body image | 20 | 17.0±8.2 | 17.1±4.5 | 16.8±11.8 | 0.093 |
Data presented as mean ± SD unless otherwise indicated.
Difference between boys and girls
Physical activity questionnaire
There was no significant difference in mean PAQ score between boys and girls (Table 3). Grades 4 to 6 students reported devoting 126 min daily (range 0 min to 330 min) to screen time (watching TV, playing video games or using the computer).
TABLE 3.
Physical Activity Questionnaire for Older Children (PAQ-C), shuttle run test and Food Frequency Questionnaire results in grades 4 to 6 students
| Characteristic | All (n=45) | Girls (n=27) | Boys (n=18) | P* |
|---|---|---|---|---|
| PAQ-C questionnaire | ||||
| PAQ-C score | 2.2±0.4 | 2.2±0.4 | 2.2±0.3 | 0.880 |
| Screen time per day, min | 126±94 | 107±83 | 164±109 | 0.117 |
| 20 m shuttle run test | ||||
| Aerobic fitness laps | 35.2±14.7 | 31.2±13.0 | 41.4±15.2 | 0.021 |
| VO2 max, mL/min/kg | 45.8±4.2 | 44.9±4.2 | 47.2±3.8 | 0.064 |
| Food Frequency Questionnaire | ||||
| Sugar-sweetened beverage, mL/week | 2735±2368 | 2377±1647 | 3309±3192 | 0.665 |
| Milk consumption, mL/week | 1503±1206 | 1491±1300 | 1521±1087 | 0.908 |
| Fruits, servings/week | 6.5±4.3 | 7.3±4.8 | 5.3±3.1 | 0.233 |
| Vegetables, servings/week | 7.1±4.6 | 8.2±4.0 | 5.5±5.1 | 0.027 |
| Fruits and vegetables, servings/week | 13.6±7.6 | 15.5±7.3 | 10.8±7.4 | 0.024 |
Data presented as mean ± SD unless otherwise indicated.
Difference between boys and girls. VO2 max Maximal oxygen uptake
Aerobic fitness
Although boys completed a significantly higher number of laps than girls on the 20 m shuttle run test (P=0.02), there was no significant difference in the VO2 max between boys and girls (Table 3).
Food frequency questionnaire
Grades 4 to 6 students reported consuming an average of 2.7 L of sugar-sweetened beverages (range 0 L to 12.4 L) and 1.5 L of milk per week (range 0 L to 5.3 L). Fifty percent of the students consumed >1 L of milk per week, and 10% of students drank <500 mL of milk per week (data not shown). All students consumed <2 servings of fruit and vegetables per day. While there were no differences between girls and boys in the intake of sugar-sweetened beverages, girls consumed significantly more vegetables and vegetable-fruit combination than boys (Table 3).
Cardiovascular risk factors
Table 4 summarizes the cardiovascular risk factors in grades 4 to 6 students. The percentage having one, two or three cardiovascular risk factor(s) was 64.4%, 42.2% and 15.6%, respectively, with no significant difference between boys and girls. No student had all four risk factors. Only three students, all of whom were girls, had low aerobic capacity.
TABLE 4.
Risk factors for cardiovascular diseases in grades 4 to 6 students
| Risk factor | All (n=45) | Girls (n=27) | Boys (n=18) | P* |
|---|---|---|---|---|
| Obese or overweight | 27 (60.0) | 15 (55.6) | 12 (66.7) | 0.456 |
| High waist circumference† | 18 (40.0) | 11 (40.7) | 7 (38.9) | 0.901 |
| Hypertension or prehypertension | 11 (24.4) | 7 (25.9) | 4 (22.2) | 0.777 |
| Low aerobic capacity‡ | 3 (6.7) | 3 (11.1) | 0 (0.0) | 0.143 |
| Having at least one risk factor | 29 (64.4) | 16 (59.3) | 13 (72.2) | 0.373 |
| Having two risk factors | 19 (42.2) | 11 (40.7) | 8 (44.4) | 0.805 |
| Having three risk factors | 7 (15.6) | 5 (18.5) | 2 (11.1) | 0.684 |
DISCUSSION
The present study is the first to report BMI and other cardiovascular risk factor data in Inuvialuit and Gwich’in children residing in the Beaufort Delta region, Northwest Territories. While the prevalence of childhood obesity and overweight in this population (49.5%) is lower than the prevalence reported (62.5%) by the 2008/2010 Regional Longitudinal Health Survey (2), it is comparable with the prevalence of 51.4% previously documented in Canadian Tsimshian Nation children living in three remote coastal communities of British Columbia (22). Notably, the prevalence of obesity in this elementary school-age population is almost double that of the non-Aboriginal Canadian population of children six to 11 years of age (24). In addition to the high rates of overweight/obesity, there was a high prevalence of other cardiovascular disease risk factors, with more than one-third of all children having elevated blood pressure as well as a central obesity (elevated WC). Notably, no sex differences were observed in terms of weight status and cardiovascular risks. In the subgroup of Grade 4 to 6 students, 64% had at least one cardiovascular disease risk factor, which is higher than previously reported (50%) by Reed et al (25) in nine- to 11-year-old Canadian children. Collectively, these data raise concerns of an unacceptably high risk for the future development of T2D and cardiovascular disease in this vulnerable population, and emphasize the need for effective obesity prevention and treatment programs.
A key component of childhood obesity treatment and prevention programs includes nutrition and physical activity education and promotion of healthy active living. While we found that Inuvialut and Gwich’in children had good knowledge (ie, nutritious foods and beverages, healthy PA) and attitude scores (ie, self-esteem scores), they had quite low behaviour scores in nutritious food consumption and healthy PA frequency. These findings are consistent with a previous study involving Caucasian elementary school-age children living on the Sunshine Coast of British Columbia (16). Given the disconnect between healthy living knowledge and behaviour, it is important that future community-based obesity treatment programs address other barriers faced by Aboriginal populations living in rural and remote regions including the high cost and limited access to high-quality nutritious foods and beverages, and limited access to indoor recreational programs over the long winter season.
The study results should be interpreted within the context of its limitations. First, data were collected from only one school. Because this is the only elementary school in the community, the results represent the prevalence of obesity and overweight in elementary school children of the entire community, but cannot be generalized to other Inuvialuit and Gwich’in communities in the Beaufort-Delta region or to youth of other age ranges. Second, it is important to recognize that our study protocol used the Centers for Disease Control and Prevention (Georgia, USA) growth charts (11), which may have underestimated the prevalence of overweight and obesity in this population compared with the WHO growth charts (26) that have since been implemented in Canada. Finally, the data regarding healthy eating habits and physical activities were collected based on self-report to questionnaires, resulting in potential recall bias. However, questionnaires with good internal validity (16,20,27) were used, and guidance from a local research assistant who had a practical understanding of local foods and physical activities was consistently provided to the children while they were answering the questions to minimize bias.
CONCLUSION
There is an urgent need for culturally and environmentally appropriate community-based approaches to address the high rates of obesity and related cardiovascular risk factors in these Aboriginal children to mitigate their diabetes and cardiovascular disease risk.
Acknowledgments
Dr Panagiotopoulos receives Clinician Scientist salary support from the Canadian Diabetes Association and the Child & Family Research Institute. This study was funded by the Canadian Diabetes Association and the Aboriginal Health Transition Fund, Health Canada. The authors acknowledge the support from the developers of the Healthy Buddies program, Dr Sue Stock, Dr Jean-Pierre Chanoine and Ms Valerie Ryden, in creating modifications required for the Healthy Buddies Questionnaire used in this study. The authors are grateful for the invaluable contributions of the community leaders, school staff and students that participated in this project.
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